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HOW TO EXAMINE THE CHEST 



HOW TO EXAMINE 
THE CHEST 

A PRACTICAL GUIDE FOR THE USE OF STUDENTS 



SAMUEL WEST, M.D. Oxon., M.E.C.P. 

physician to the city of london hospital fob disease8 of the chest, victoria 

pabk; medical tutor and medical registrar at st. Bartholomew's 

hospital; and assistant physician to the royal free hospital 



PHILADELPHIA 

BLAEISTON, SON, & CO. 

1012, WALNUT street 

1883 



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PBEFACE. 



In the following pages I have not aimed at 
writing an exhaustive treatise on auscultation 
and percussion, but merely an introduction to 
the examination of the chest by these and other 
methods. Each section is virtually based on 
lectures delivered by me at St. Bartholomew's 
Hospital, during the course of the demonstrations, 
which it has been my duty, as medical tutor, to 
give to the students during the last few years, by 
way of preparation for clinical work in the medical 
wards. I have therefore avoided all discussion 
of theory, and have adopted in the text, without 
argument, that theory in each case which appears 
to me on the whole to furnish the best explana- 
tion of the facts. 

I have endeavoured throughout to keep clearly 
in view the wants of beginners, and to write a 
simple and concise account of the main facts of 
prominent importance, describing what seems to 



VI PEEFACE. 

me the best method of observing these facts, 
and showing the use which may be made of them 
for the purpose of diagnosis. 

I am much indebted to Dr. Andrew and Dr. 
Bristowe for their friendly criticism and advice, 
which I take this opportunity of gratefully 
acknowledging. 

SAMUEL WEST. 

15 Wimpole Street, 

Cavendish Square, W. 
March, 1883. 



CONTENTS. 



INTRODUCTORY CHAPTER. 
The Thorax 

The Parts of the Thorax 
The Contents of the Thorax 
The Position of the Patient 
The Methods of Examination 



SECTION I.— THE LUNGS. 

1. Inspection. 

a. The Shape of the Chest 
Its Measurement 

Named Varieties of Thorax 

Changes of Shape due to Disease 

Deformities 

The Condition of the Superficial Veins 

b. The Movements of the Chest on Respira 

tion 
The Types of Respiration 
The Amount of Air Respired 
Alterations in the Respiratory Movements 
The Number of Respirations 
Synopsis 

2. Palpation. 

How to Count the Ribs . 

The Shape and Movements of the Chest 

Abnormal Sensations 

The Vocal Vibrations 

Sense of Resistance 

Synopsis 



PAGE 

1 
1 

3 
3 
5 



9 
10 
12 
18 
19 
19 

20 
20 
21 
22 
23 
26 

27 
27 
28 
28 
29 
30 



Vlll CONTENTS. 



SECTION L— THE LUNGS (continued). 




3. Percussion. 


PAGE 


Method of Percussion 


. 31 


Resonance and Dulness . 


. 31 


Boundaries of the Lungs . . 


. 37 


The Surface Markings of the Liver 


. 39 


Do. of the Spleen 


. 43 


Do. of the Stomach 


. 43 


Alterations in the Boundaries of the Lungs 


. 45 


Symmetrical 


. 47 


Unsymmetrical 


. 49 


Varieties of Percussion Sounds 


. 51 


Want of Symmetry on Percussion . 


. 56 


Synopsis 


. 59 


4. Auscultation. 




Of Stethoscopes 


60 


Vocal Resonance and its Varieties . 


64 


The Sounds of Breathing and their Varieties 


70 


Use of the Facts ascertained in Diagnosis 


77 


Other Pulmonary and Pleural Sounds 


81 


Synopsis 


89 


Conclusion 


91 


Suggestions for the Construction of Diagrams 


91 


General Synopsis of the Examination of the Lungs 


93 


SECTION II.— THE HEART. 




1. Inspection, 




The Shape of the Precordial Region 


98 


The Movements in the Precordial Region : 




Apex Beat : 




Its Normal Position 


99 


Normal Peculiarities 


100 


Displacement . 


100 


Its Character . 


102 


Changes in Disease 


102 


Pulsation in Abnormal Places . 


103 


Synopsis . 


105 



CONTENTS. IX 



SECTION II.— THE HEART (continued). 






2. Palpation. 




PAGE 


How to Fix the Apex 




106 


Abnormal Sensations 




106 


Synopsis 


. 


108 


3. Percussion. 






The Size of the Heart and the 


Cardiac 




D ulness 




109 


Alterations in the Cardiac Dulness 




113 


Synopsis 




117 


4. Auscultation. 






The Sounds of the Heart 




120 


Asystolism 




123 


Murmurs 




124 


Their Classification . 




125 


How to Time them . 




126 


Subdivision of 




128 


Their Cause 




132 


Their Place 




133 


The Position of the Valves 




135 


The Axes of the Heart 




137 


The Diagnosis of Valvular Disease . 




141 


Inorganic Murmurs — Endocardial . 




145 


Exocardial . 




149 


Murmurs Audible in other Parts 


of the 




Thorax 




151 


Synopsis . 




154 


General Synopsis of the Examination of the 




Heart 




155 


SECTION III.— THE PULSE. 






Its Cause 




159 


The Pulse Eate 




159 


The Artery. 






Its Course 




161 


Its Coats 




161 


Its Calibre 


b 


162 



X CONTENTS. 

SECTION III.— THE PULSE {continued). 

The Pulse Wave. page 

The Sphygmograph . . . 165 

The Khythni of the Pulse . . 170 

Want of Symmetry . . .173 

Synopsis .... 175 

SECTION IV.— THE MEDIASTINUM. 

Dislocation of the Mediastinum . . 179 
The Parts of the Mediastinum . . 181 
Diseases of the Mediastinum and their Dia- 
gnosis . . . . 184 
Synopsis .... 190 



LIST OF ILLUSTRATIONS. 



7, 

8, 

9 

10 



12. 
13. 
14. 
15. 
16. 

17. 

18. 
19. 



1. The front of the thorax 

2. The back of the thorax 
Cyrtonieter tracings : 

3. of the healthy chest 

4. of an emphysematous chest 

5. of a rickety chest 

6. of a pigeon-breast 

of an alar or pterygoid chest 

of an unsymmetrical chest 

tracing of Cheyne Stokes's breathing 

Diagram showing position of the thoracic and abdo 

minal organs, with their surface markings 
11. Diagram showing the boundaries of the lungs in 

health 

in emphysema 

in senile emphysema 

in compensatory hypertrophy 

in pneumothorax 

in pleuritic effusion 

Figure of stethoscopes : 

the single 

the binaural and differential 

Diagram showing the position of the bronchi behind 
20. Diagram showing the real size of the heart, and the 

size of the absolute cardiac dulness 



PAGE 

4 
5 

10 
13 
15 
16 
16 
19 
25 

36 

42 
46 
48 
50 
52 
54 

62 
63 
72 

110 



Xll 



LIST OF ILLUSTKATIONS. 



PAGE 



Alterations in cardiac dulness : 

21. in aortic disease 

22. in mitral disease 

23. in pericardial effusion 

24. Diagram of the heart's action 

25. Diagram of a systolic murmur 

26. Diagram of a presystolic murmur 

27. Diagram of a short postsystolic murmur 

28. Diagram of a long postsystolic murmur 

29. Diagram of a systolic and postsystolic murmur 
Diagram of a presystolic and systolic murmur 
Diagram of the position of the different parts of the 

heart, and of the places at which to examine the 

orifices and the axes of the heart 
32. Diagram of the hand on the chest to represent the 

heart ..... 
Diagram of the area of cardiac dulness in a case of 

mitral stenosis . . . 

Diagram of the murmurs and of the heart sounds in 

the same case .... 

Pulse tracings : 

35. diagrammatic .... 

36, 37, 38, 39, and 40. — - in health and in disease 166, 170 

41. of the pulsus paradoxus . . . 172 

42. Diagram of the chest in a case of mediastinal 

tumour .... 182 



30. 
31. 



33. 



34. 



114 
115 
116 
119 
127 
129 
130 
130 
131 
131 



134 



136 



143 



144 



164 



HOW TO EXAMINE THE CHEST. 



INTRODUCTORY CHAPTER. 

THE THORAX. 

The Chest or Thorax is a "box, the sides of 
which are formed by the spine, the ribs and 
intercostal muscles, and the sternum. 

Above, it is closed by muscles and membrane, 
between which the vessels and other structures 
pass into, or out of, the cavity of the chest. 

Below, it is completely closed by the diaphragm, 
which is attached, posteriorly to the spine, ante- 
riorly to the sternum, and all round to the free 
margin of the ribs, or, as it is called, the Costal 
Arch. 

The Parts of the Thorax. 

Externally, the thorax is mapped out into 
certain regions (figs. 1 and 2), named according 
to the anatomy of the part : 

1 



2 HOW TO EXAMINE THE CHEST. 

In the middle line, the Sternal, divided into 
the Upper and Lower Sternal, with 
the Episternal above : 
On either side of the sternum, 

the Parasternal : 
Further outwards, 

the Clavicular, 

the Supraclavicular and Infraclavicular, 
the Mammary and Inframammary : 
Laterally, 

the Axillary, upper and lower : 
Posteriorly, 

the Supraspinous, and Infraspinous, 
the Infrascapular and the Interscapular. 
These terms are useful as indicating roughly 
the particular region under examination, but, 
when greater accuracy is required, the locality 
should be fixed by reference to parts of the bony 
framework, such as the ribs, sternum, &c. 

Measurements are often taken from the nipple 
as a fixed point, or from a vertical line passing 
through the nipple, and called the Nipple line ; 
but from the varying position which the nipple 
occupies, in different persons, especially in women, 
such measurements are not satisfactory. 

The line which is usually described as the 
nipple line is a vertical drawn from the middle 
point of the clavicle downwards. This cuts the 
edge of the costal arch, usually at the tip of the 



THE THORAX. 3 

eighth rib, and in ordinary cases passes through 
the nipple. 

The Contents of the Thorax. 

The thorax contains : 

1 . The Lungs. 

2. The Heart. 

3. The parts in the Mediastinum. 
Closely related as all these organs are to one 

another, it is impossible to limit our examination 
absolutely to one or other of them ; but for 
convenience we may divide our subject in this 
way, making reference, in our description of one 
organ, to the others, only so far as may be 
necessary for clearness. 

Position of the Patient. 

When the chest is being examined, it should, if 
possible, be completely bare. 

To examine the front of the chest, the patient 
should stand, or sit, straight up, with the arms 
hanging down, or, if lying down, should be flat 
upon the back, with the arms by the side and the 
legs straight. 

To examine the back of the chest the patient 
should sit or stand with the arms folded, the 
shoulders rounded, and the head bent forward, 
so as to make the back as broad and round as 
possible, and to widen the interscapular spaces. 



HOW TO EXAMINE THE CHEST. 

Fig. 1 




Diagram of the front of the thorax and abdomen. 
The vertical lines are the nipple lines. The figures refer 
to the named regions. 

1. The supraclavicular. 

2. The clavicular. 

3. The infraclavicular. 

4. The mammary. 

5. The inframammary. 

6. The hypochondriac. 

7. The epi sternal. 

8, 9, 10. The upper, middle, and lower sternal. 
11. The epigastric. 
The umbilical. 
The hypogastric. 
The lumbar. 
The inguinal. 



12. 
13. 
14. 
15. 



THE THORAX. 
Fig. 2. 




Diagram of the back of the thorax. The letters refer to the 
named regions. 

A. The supraspinous. 

B. The infraspinous. 

C. The infrascapular. 
D, E. The interscapular. 

The Methods of Examination. 

In our examination of the chest we use the 
senses of sight, touch, and hearing, and we 
arrange our observations accordingly, under the 
three heads of : 

1. Inspection, i.e. what we can see. 

2. Palpation, i.e. what we can feel. 

3. Auscultation and Percussion, i.e. what we can 
hear. 

These methods are applicable to all parts of 



6 HOW TO EXAMINE THE CHEST. 

the body, though, not in an equal degree, but 
they are of chief importance in the examination 
of the chest. 

Any other methods which may be available in 
certain cases will be referred to and described as 
occasion arises to make use of them. 

It is desirable, so far as possible, to represent 
in a graphic form all the information we obtain. 
Ways of doing this will be suggested as oppor- 
tunity offers. 

We shall commence with the systematic exa- 
mination of the lungs, then proceed to the 
examination of the heart, and lastly, of the 
mediastinum. 

Our observations will be arranged in order 
under the heads of Inspection, Palpation, Percus- 
sion, Auscultation. 



SECTION I. 



THE LUNGS. 



THE EXAMINATION OF THE 
LUNGS. 



INSPECTION. 

When we inspect, or look at, a chest we have 
two sets of facts to observe : 

1st. Those, which we can observe as well in a 
dead as in a living person, viz. the Shape or Form 
of the chest : 

2nd. Those, which are only seen during life, 
viz. the Movements of the chest during respira- 
tion. 

I omit, for the present at any rate, all those 
phenomena not associated with the form or move- 
ments of the chest, such as dilated veins, &c, as 
not immediately connected with the examination 
of the lungs. 

THE SHAPE OE THE CHEST. 

This admits of great variation, even within the 
limits of health, so that there is no fixed normal 
or physiological type. 



10 HOW TO EXAMINE THE CHEST. 

Average Measurements of Healthy Chests. 

The healthy adult thorax (fig. 3) is wider than 
it is deep, that is, it measures more transversely 
than from front to back. In a fully-developed 
man the average measurements are transversely 

Fig. 3. 



Healthy chest. Cyrtometer tracing reduced. 

9 to 10 inches, and antero-posteriorly 6 to 7 inches. 
In ivomen these measurements are about 1 inch 
less. 

These are of course only rough averages and 
vary much in different individuals. In children 
the two diameters are nearly equal, so that the 
shape becomes almost circular. 



THE LUNGS. INSPECTION. 11 

The apparatus required for measuring the 
chest consists of : 

1. A measuring tape. 

2. A pair of callipers. 

3. A cyrtometer. 

The Cyrtometer is an apparatus by means of 
which a life-size tracing may be obtained of the 
shape of the chest. 

There are many forms of cyrtometer, but the 
most convenient, and that in ordinary use, is 
made of two pieces of composition gas-piping, 
each about eighteen inches long, and joined 
together by a hinge or piece of gutta-percha 
tubing. 

The method of using this apparatus is as 
follows : 

The patient's chest being bare, a mark is made 
at the base of the xiphoid cartilage in front, and 
another posteriorly upon the spine, on the same 
horizontal level. With a pair of callipers, the 
measurement is taken between these two points, 
and two marks made upon a sheet of paper, 
corresponding with the points of the callipers, 
" spine " being written opposite one, and u ster- 
num" opposite the other. 

The cyrtometer is then taken, the hinge 
placed upon the mark upon the spine, and the 
soft piping bent round the ribs, until the two 
arms meet at the mark in front. A little careful 



12 HOW TO EXAMINE THE CHEST. 

moulding causes the piping to take the form of 
the chest. A mark is now made upon the piping 
in front, to indicate the spots upon the two arms 
corresponding with the middle line of the sternum. 
The cyrtometer is then held by the hinge, and 
the two arms allowed to fall off the chest by 
their own weight, care being taken that they 
are not twisted in any way, as they are removed. 

The whole apparatus is now laid upon the 
sheet of paper, so that the hinge corresponds 
with the spine mark, and the marks upon the 
cyrtometer in front, with the sternum marks. 
A pencil is carried round the inside of the arms, 
and an exact tracing of the shape of the chest is 
thus obtained. 

Lastly, the words " Right ; ' and "Left" are 
written on the corresponding sides, and the 
tracing is complete.* 

Named Varieties of Thorax. 

The different forms of chest are for the most 
part described by ordinary terms, such as long 
and short, broad and narrow, deep and shallow, 
and all of these various forms may be quite con- 
sistent with health. 

* By means of a very simple apparatus, such as the pan- 
tograph, a cheap form of which may be purchased now for 
one shilling, these large tracings may be quickly reduced to a 
convenient size for the note book. 



THE LUNGS. 



INSPECTION. 



13 



Certain marked deviations from the normal 
form have, however, received special names. 
These are : 

1. The Barrel-shaped chest. 

2. The Rickety chest. 

3. The Pigeon-breast. 

4. The Alar chest. 

The Barrel-shaped Chest is, as its name 
implies, like a barrel {fig. 4). It is almost 

Fig. 4. 




Barrel-shaped chest. Cyrtonieter tracing from a case of 
emphysema reduced. 

This is very like the tracing obtained from an infant's chest, 
which is also nearly circular in shape. 



circular in section. Its transverse and antero- 
posterior diameters are almost the same. The 
sternum is bowed forwards, and the spine often 



14 HOW TO EXAMINE THE CHEST. 

backwards, so that, in profile, the outline is 
usually distinctly bi-convex. 

This form is always associated with a patho- 
logical change in the lungs, to which the name 
emphysema is given. 

The other peculiar forms of chest are not 
necessarily associated with any change in the 
lungs. They are due to causes which were at 
work when the chest was developing in child- 
hood, at a time when the ribs were soft and 
yielding, and are evidence rather of past than of 
present disease, although in all these cases it is 
very common, that the lungs are weak, and that 
they subsequently become affected. 

The Rickety Chest gives a tracing such as is 
shown in fig. 5. The longitudinal furrow at the 
sides of the sternum corresponds with what was 
in childhood the ossifying end of the ribs. Most 
rickety children suffer much from bronchitis, and 
the bronchi in children become easily plugged. 
When this is so, the air cannot enter freely into 
the air vesicles, and on inspiration the chest walls 
are driven in by atmospheric pressure. The 
softest parts yield most. These are, of course, 
the ossifying ends of the ribs and cartilages, 
which are, moreover, in rickets especially soft 
and yielding. If this condition lasts for any 
length of time, it may become permanent and 
give rise to the rickety form found in adults. 



THE LUNGS. INSPECTION. 



15 



In rickety children a deep transverse furrow 
running across both sides of the chest below the 
nipples, about on a level with the fifth space, is 
often seen. This is called Harrison's furrow. 
When well marked, its causes are the same as 
that of the rickety chest. It is most evident on 
the right side and corresponds with the upper 
border of the liver in childhood. It may be 
traced, though often indistinctly, in most healthy 

Fig. 5. 




Rickety chest. The diagram shows a slight want of sym- 
metry as is not uncommon in these cases. 



adults, but when excessive, is usually evidence of 
past lung affection. 

In the Pigeon-breast {fig. 6) the sternum is 
protruded and the ribs straightened out at the 
angles and at their junctions with the cartilages. 
In external appearance it resembles, as the name 



16 



HOW TO EXAMINE THE CHEST. 



Fig. 6. 




The Pigeon-breast. Here also is a slight want of symmetry. 



Fig. 7. 



The Alar or Pterygoid Chest. This is a good instance of a 
tracing of a flat chest. 



THE LUNGS. INSPECTION. 17 

implies, the carinate or keel-shaped breast of a 
pigeon. 

This is merely a variety of the rickety chest, 
and is due to the same causes. 

In the Alar Chest or Pterygoid Chest [fig. 7), 
the upper parts of the chest, viz. the sternum 
and neighbouring ribs, are flattened and sunken. 
The shoulders in consequence fall forward, and 
thus throw the posterior and lower borders of 
the scapulas off from the ribs, so that they are 
tilted outwards and project like rudimentary 
wings (alse), whence the name. 

With this peculiar deformity, the muscles con- 
nected with the upper part of the thorax are 
usually imperfectly developed or atrophied, and 
in consequence, this has been also called the 
Paralytic form of thorax. 

This, like the other forms, though presumptive 
of disease of the lungs, is not necessarily asso- 
ciated with it. 

The healthy chest is as nearly as possible 
symmetrical in all its parts. Any want of sym- 
metry, even though it be but slight, is most 
important evidence of disease, either past or 
present.* 

* The right side of the chest usually measures about half 
an inch more in circumference than the left ; probably in con- 
nection with the greater development of the muscles on the 
right side in right-handed persons, but this does not give any 
appearance of asymmetry to the eye. 

2 



18 HOW TO EXAMINE THE CHEST. 

Changes of Shape due to Disease. 

In disease the changes of shape may be of two 
kinds. There may be— ?- 

1st. Increase in size, or as it is usually called, 
Bulging ; 

2nd. Decrease in size, or Contraction. 

These changes may affect both sides, i.e. be 
bilateral, or only one side, i.e. be unilateral, and 
in either case they may involve either the whole 
of the side, or only part of it. 

Even where the change is bilateral, it is rarely 
absolutely symmetrical. 

Symmetrical bilateral increase in size is only met 
with in the barrel- shaped chest of emphysema. 

Symmetrical bilateral decrease in size occurs 
only in the opposite condition, in which both 
lungs are uniformly shrunken, and more rarely 
also in the paralytic, alar, and other forms of 
chest described above. 

With these exceptions, changes in shape are 
always unsymmetrical, and it is therefore for a 
Want of Symmetry, i.e. for a difference between 
the corresponding parts of the two sides of the 
chest, that we chiefly look as evidence of disease 

(fig- 8). 

When there is such a want of symmetry it is 
sometimes difficult to say whether this want is 
due to a bulging of one side, or to a shrinking of 



THE LUNGS. INSPECTION. 19 

the other. Further examination only can deter- 
mine this question, 

' Fig. 8. 




An extreme instance of want of symmetry. The tracing was 
taken from a child in whom the left side was contracted after 
an empyema. 

Deformities. 

In certain trades, for instance, among car- 
penters, weavers, and shoemakers, a depression is 
often found at the bottom of the sternum, some- 
times of considerable depth. This is usually 
due to pressure during work (as by the last, 
auger, or weavers' beam), though the deformity 
is occasionally congenital. 

The Condition of the Superficial Veins. 

Except where patients are very thin, the veins 
are rarely visible in health beneath the skin. 



20 HOW TO EXAMINE THE CHEST. 

In disease they are often dilated and frequently 
unsymmetrically so. When this occurs, the 
direction in which the blood is travelling should 
be determined. This is done by placing two 
fingers upon the most prominent vein, and then 
drawing them apart along the vein in order to 
press the blood out. By raising first one finger 
and then the other, it will be clear from which 
direction the vein fills most easily. This will 
be then the direction, in which the blood is 
travelling.* 

THE MOVEMENTS OF THE CHEST ON RESPIRATION. 

These are alternately movements of expansion 
and contraction, called inspiration and expiration. 
On inspiration the chest expands in all directions. 
The sternum moves forward, the ribs rise, the 
intercostal spaces widen, and the diaphragm 
descends. These movements are freest in the 
lower parts of the chest. They are partly 
thoracic and partly diaphragmatic. 

In women and children the ribs move most, 
and the respiration is called Thoracic or Costal. 

In men the diaphragm moves most, and the 
respiration is called Diaphragmatic or Abdominal. 

* Enlarged subcutaneous veins over the mammae and upper 
part of the chest are usual in women who are suckling, or 
who have had children. This is, of course, physiological. 



THE LUNGS. INSPECTION. 21 

A change of type from costal to abdominal or 
vice versa is often an evidence of disease. 

The Measurements of the chest are constantly- 
varying. The average circumference of a healthy 
man's chest at the level of the nipple is after 
expiration about 32 inches,, and after inspiration 
about 35^ inches, giving thus a difference on the 
average of each respiration of 3£ inches, or about 
one twelfth. On forced respiration the difference 
can sometimes be made much greater. 

These measurements in women are somewhat 
less. 

The Amount of Air, which is taken in and out, 
will depend upon the amount of the respiratory 
movement of the chest. 

In ordinary breathing it is calculated that on 
the average about 30 cubic inches are drawn in at 
each inspiration, and the same quantity emitted 
at each expiration. About 100 cubic inches more 
may be squeezed out on forced expiration, and 
about the same amount more taken in on forced 
inspiration. Making the total maximum quantity 
of air which can be inspired or expired about 
230 cubic inches. 

Instruments have been devised for measuring 
the Vital Capacity of the chest, i.e. the total 
amount of air, which can be taken in, or forced 
out, by the deepest possible respiration. They 
are known as Spirometers, but hitherto they 



22 HOW TO EXAMINE THE CHEST. 

have not been found to be of much use in 
diagnosis. 

Alterations in the Respiratory Movements. 

When the respiratory movements are increased 
in range above the normal, we speak of them as 
Exaggerated ; when decreased below the normal, 
we speak of them as Impaired or Deficient. 

When the movements are deficient, less air will 
enter the lungs than is necessary, and the patient 
will suffer from shortness of breath, or as it is 
called Dyspnoea (bad breathing). 

Dyspnoea may be the result of deficient respi- 
ratory movements under two opposite conditions, 
for the lungs may be prevented either from 
expanding, or from contracting, as much as they 
should. The former is spoken of as Defective 
Inspiration or Deficient Expansion, and the dysp- 
noea is called Inspiratory ; the latter, as Deficient 
Expiration, and the dyspnoea is called Expiratory. 

When the patient cannot lie down on account 
of the difficulty in breathing, it is called not 
dyspnoea, but Orthopncea (orthos, upright). 

When from any cause there is obstruction to 
the entrance of air, the deficient expansion of the 
lungs will make itself manifest in the softer parts 
of the thorax, i.e. in the intercostal and supra- 
clavicular spaces, and they will sink in somewhat 



THE LUNGS. INSPECTION. 23 

during inspiration. This is called Inspiratory 
Recession. 

When the obstruction is considerable, not only 
the soft parts, but also the ribs, especially the 
lower ones, yield, and are sucked in during inspi- 
ration. In its most extreme form, this is met with 
in children suffering from croup, and where the 
obstruction is of long standing, or oft repeated, 
as has been stated already, it is the cause of 
certain deformities, which may be permanent 
(p. 14). 

The exactly opposite condition to inspiratory 
recession, viz. Expiratory Bulging of the inter- 
costal and supraclavicular spaces, is common in 
cases in which the elasticity of the lungs is 
reduced, and the expiration obstructed. 

It is most marked during a fit of coughing, in 
patients suffering from extreme emphysema. 

The Number of Respirations is about 14 to 18 
in the minute, and bears to the pulse, on the aver- 
age, the relation of 1 to 4. 

On quiet respiration, the movements occur at 
regular intervals, though they are largely influ- 
enced by emotion and excitement, both as regards 
number and regularity. 

Except in children and in cases of hysteria, the 
number, even in disease, rarely exceeds 40 to 
50. As a general rule the more rapid the 
respirations, the more shallow they are. 



24 HOW TO EXAMINE THE CHEST. 

The movements of respiration, in healthy per- 
sons at perfect rest, as for instance when asleep, 
follow one another at regular intervals, the 
rhythm being maintained by the action of the 
nerve centres in the medulla oblongata. 

The movements are to a very great extent 
under voluntary control, and may therefore be 
made to vary much by the action of the will, as 
in speaking, singing, &c, but irregularity is often 
independent of the will, and is due then to inter- 
ference with the action of the respiratory centre, 
usually in response to reflex irritation from some 
other part. Thus, mental emotion may lead to 
laughing, crying, sobbing, &c, irritation in the 
lungs or stomach to coughing, hiccough, &c. 

Of all forms of irregular respiration the most 
peculiar is that known by the name of Cheyne- 
Stokes' Breathing * 

In this form the respiration at times ceases for 
some seconds, and then recommences, the move- 
ments being at first small and rapid, becoming 
gradually deeper, and often at the same time 
slower, until the maximum expansion of the 
chest is reached, when they decrease in the same 
manner, until again for a time the movements 
cease {fig. 9). 

In all these cases the movements still remain 

* Dr. Cheyne first observed it and Dr. Stokes subsequently 
more minutely described it. 



THE LUNGS. INSPECTION. 25 

symmetrical. They are altered in their general 
rhythm, but not in symmetry. When the move- 
ments are unsymmetrical, there is some local dis- 
ease, past or present, to account for it. 

Fig. 9. 




A semi-diagrammatic tracing of Cheyne-Stokes* Breathing. 
The upstrokes represent inspiration, the downstrokes expiration. 

The more or less horizontal line indicates the pause in respi- 
ration. 



Inspection of the chest presents but few diffi- 
culties, if it be remembered, that, with the excep- 
tions to which reference has been made, what 
we have to look for is not a departure from some 
ideal normal type to be carried in the memory, 
but simply a want of symmetry, or similarity, 
between the two sides of that particular chest, 
which we are examining. 

"When this want of symmetry exists, there 
must be some condition of disease, past or pre- 
sent, to account for it. 



26 HOW TO EXAMINE THE CHEST. 



SYNOPSIS. 

On Inspection then we note — 
I. The shape of the Chest: 

Barrel. 

Rickety. 

Pigeon. 

Alar. 

Paralytic. 

Shoemakers', Weavers', Carpenters'. 

Harrison's Furrow. 

Defects of Symmetry. 
II. The Movements of the Chest : 
their number, 
their regularity, 

their type, costal or diaphragmatic, 
if impaired, 
or exaggerated, 
Defects of Symmetry. 

Dyspnoea! *"&***• 
I Expiratory. 

Orthopnea. 



THE LUNGS. PALPATION. 27 



PALPATION. 

The first thing to be done on palpation is to 
Count the Ribs, and, simple as this seems to be, 
mistakes are often made. It will be easily and 
correctly done, if it be remembered, that the 
first rib, which we can get comfortably between 
two fingers, is the second. It is easier to count 
the spaces than the ribs, and we know, that the 
rib corresponding to the space lies above the 
space. 

Our landmarks, as we shall see, are all deter- 
mined with relation to the ribs and spaces. 

THE SHAPE AND MOVEMENTS. 

Nearly all that can be seen can be also felt, 
but sometimes, in case of difficulty, the hand 
may help the eye. This is especially the case with 
the movements of the chest. For this purpose, 
the hands must be placed symmetrically upon 
symmetrical parts. If at the apices, the thumbs 
should be placed together upon the sternum, and 
the fingers allowed to rest beneath the clavicles, 
or, in children, the thumbs may be placed in con- 



28 HOW TO EXAMINE THE CHEST. 

tact upon the spine, and the fingers bent over 
the shoulder, so as to rest upon the upper part 
of the chest in front. In either of these ways 
very slight differences in the amount of move- 
ment upon the two sides may be detected. 

The Widening of the Intercostal Spaces on in- 
spiration may be easily observed, by placing the 
hands upon the lower part of the chest or in the 
axilla and spreading the fingers so that they lie 
in the intercostal spaces. 

We are able in this way to determine : 

1. If the spaces be narrower or wider on one 
side than on the other ; 

2. If they be retracted or unduly prominent; 

3. If the expansion or widening on inspiration 
be sufficient in amount, and equal on the two 
sides. 

Abnormal Sensations. 

Occasionally the grating of Pleuritic Friction, 
(q. v.), the wheezing of Rhonchus and Sibilus, 
(q. v.), or the crackling of Crepitation, (q. v.), 
may be felt. 

YOOAL VIBRATIONS. 

If, while the hand is placed upon the chest, the 
patient be made to speak, the vibrations of the 
voice will be felt by the hand. They are called 
Vocal Vibrations. They may be also heard, if the 



THE LUNGS. PALPATION. 29 

ear be placed upon the chest, as we shall see under 
" Auscultation," and then they are spoken of as 
Vocal Resonance. There is no real difference 
between them except one of terms. We feel 
vocal vibrations, and we listen to vocal resonance. 
As the ear is more sensitive than the hand, so we 
can occasionally hear the vocal resonance, when 
we cannot feel the vocal vibrations. This is 
especially the case in women and children, in 
whom the vibrations of the voice are not intense. 

The louder the voice, the deeper or more bass 
the tone, and the thinner the patient, the more 
easily will the vibrations be felt. The other con- 
ditions, which alter the vocal vibrations, will be 
discussed later under the head of "Auscultation," 
when we speak of vocal resonance. 

For the present it is sufficient to say, that the 
same want of symmetry in the physical signs, 
which we look for on inspection, is to be searched 
for also on palpation. It is this want of sym- 
metry, which is of the chief practical importance. 

Sense of Resistance. 

If the intercostal spaces be lightly tapped with 
the tips of the fingers over the upper part of the 
chest, a sensation of elasticity or springiness will 
be obtained. If, however, the same thing be done, 
where a solid organ lies beneath the chest walls, 



30 HOW TO EXAMINE THE CHEST. 

as over the liver, the sense of elasticity will be 
lost, and, in its place, the fingers will experience 
a feeling of resistance. 

The same thing happens, if the lung becomes 
solid, or if it be separated from the chest walls 
by changes in the pleura. To this feeling the 
name Sense of Resistance is given. It is, how- 
ever, of no great practical importance. 

Where, in disease, there is a large collection of 
pus in the pleura, Fluctuation may sometimes be 
elicited in the usual way. It is not, however, at 
all common. 



SYNOPSIS. 

On Palpation, then, we proceed to count the ribs, 
and next to observe : 

1. The Shape and Movements of the Chest. 

2. The Vocal Vibrations. 

3. The Sense of Resistance. 

4. Abnormal Sensations, when present, such as 
friction, crepitation, rhonchus, sibilus, or pos- 
sibly fluctuation. 



THE LUNGS. PEECUSSION. 31 



PEKCUSSION. 

By Percussion is meant the method of striking 
the walls of the body, so as to cause them to 
yield a sound. 

We must consider, then, 1st, the best way of 
producing sound by percussion, and 2ndly, the 
kinds of sounds, which may be produced, and what 
meaning and value we may attach to them. 

Percussion may be direct (immediate), when we 
percuss upon the skin directly, or indirect (me- 
diate), when we percuss upon something placed 
upon the skin. 

In the examination of the Chest Direct Per- 
cussion is not employed now except upon the 
clavicles and the spine of the scapula, where, 
from the absence of much covering, the sound 
produced is not interfered with. 

For Indirect Percussion we require : 1st, some- 
thing to strike with, and 2ndly, something to 
strike upon. 

Apparatus of various kinds has been devised 
for this purpose : — 1. Hammers, or, as they have 
been called, Plessors, of various sizes, shapes, and 
substances, to strike with. 2ndly. Flat plates, 
(Plessimeters) of metal, wood, or ivory, to strike 
upon. 



32 HOW TO EXAMINE THE CHEST. 

Tliese forms of apparatus have been almost 
entirely abandoned, and in their place we are in 
the habit of using the fingers of one hand, as our 
plessor, to percuss with, and one of the fingers of 
the other hand, as our plessimeter, to percuss 
upon. 

In this way we combine, with percussion, those 
sensations described in the previous chapter under 
the head of " Sense of Resistance." This method 
of percussion has been called Palpatory Per- 
cussion. 

The tip or pad of one finger, say the middle, 
is the head of the hammer, the rest of the hand, 
the handle. 

The blow should be light, but firm, produced 
by a free action of the wrist, as in playing octaves 
upon the piano. This is difficult to acquire, but 
can be well practised by placing the whole 
forearm, from the elbow to the fingers, flat upon 
a table and then percussing, the forearm being 
firmly pressed down with the other hand, to keep 
it fixed, and to prevent its being raised from the 
table. 

The hammer of a piano forms the best illustra- 
tion of the kind of movement we require. When 
a note is struck upon the key-board, the hammer 
is driven sharply against the wire, but does not 
remain more than an instant upon it, quickly 
recoiling and leaving the wire free to vibrate. 



THE LUNGS. PEECUSSION. 33 

This is wliat the hand should do. The finger 
should deliver a short, sharp stroke, and imme- 
diately return from contact with the chest. It 
will require much practice to get this proper 
movement. . 

Sometimes, instead of the tip of one finger, the 
tips of two or three are employed. This has no 
special advantage, except, that as the head of the 
hammer is broader, a greater surface is thrown 
into vibration, and therefore the sound is some- 
what louder, but, if more fingers than one are 
used, care must be taken that the pads of the 
fingers are all upon the same level, so that they 
may all strike the chest at the same time. This, 
again, can be practised best upon the table, by 
pressing first the tips of the fingers firmly down 
to get them level, then raising them, fixed in that 
position, and proceeding to percuss. 

In choosing a finger to percuss upon, one should 
be selected which is not bandy, so that it may lie 
perfectly flat. It matters little which is chosen. 
For convenience, it is generally either the index 
or the little finger. 

The object we have in view in percussing the 
chest is to throw into vibration the parts beneath 
the walls of the thorax. We must, therefore, avoid 
as much as possible all interference with these 
vibrations from the walls themselves. This we 
do by placing the finger upon which we percuss 

3 



34 HOW TO EXAMINE THE CHEST. 

perfectly flat upon the chest, and exercising slight 
pressure, so as to condense the tissues imme- 
diately beneath. If the finger be placed loosely, 
instead of firmly, upon the skin, and still more if 
it be not in all parts quite in contact the percus- 
sion note will be impaired. 

In order that there may be as little of the walls 
as possible for the vibrations to pass through 
before reaching the organs beneath, we must per- 
cuss straight upon the surface, that is, perpendi- 
cularly to the walls and not in a slanting direc- 
tion. 

To sum up — 

1st. Our hands form our only apparatus. 

2nd. The finger percussed upon must be placed 
flat, and pressed firmly upon the chest. 

3rd. The blow must be from the wrist, light, 
short, firm, and delivered at right angles to the 
chest walls at the part percussed. 

Good percussion is difficult to acquire, but is 
worth all the time and trouble spent upon it. 

Resonance and Dulness. 

When we percuss upon the walls of a cavity 
containing air, as, for instance, over a drum, we 
obtain a hollow or, as it is called, a resonant sound. 

When we percuss upon a solid mass, like the 
thick part of the thigh, the hollow sound is not 



THE LUNGS. PERCUSSION. 35 

produced, and the sound which is produced is 
called non-resonant or dull. 

Many varieties of resonance and non-resonance 
are described, but it is sufficient for us at pre- 
sent to recognise the difference between sounds 
which are resonant, and those which are non- 
resonant. 

Over the lungs the note is resonant, because 
the lungs contain air. Over a solid organ, such 
as the liver, the note is non-resonant or dull. 

The Size of the Lungs. 

We are now in a position to apply these facts 
practically. 

How large are the Lungs ? This is naturally the 
first question of importance, and percussion alone 
enables us to answer it. For the lungs are in 
direct relation with solid organs, and, where these 
are, the note, which over the lungs has been 
resonant, will become non-resonant or dull. If we 
mark upon the skin of the chest the places where 
this occurs, we obtain certain lines. These are 
called Surface Markings, or Medical Landmarks. 

These landmarks indicate certain relations in 
which the organs stand to the outer parts of the 
body. They must not be confounded with the ana- 
tomical boundaries, sizes, and shapes, of these dif- 
ferent organs, with which they only approximately 



36 



HOW TO EXAMINE THE CHEST. 




Diagram showing the position of the great organs of the thorax and abdomen 

with their surface markings. 

L, Liver, st, Stomach, s, Spleen, k, Kidney, c, Colon. 

The Lungs are left unshaded. Their upper and anterior boundaries only 
are shown by a dotted line. 

The Heart is represented of its anatomical size, and upon it in black is 
indicated the size of the absolute cardiac dulness. 

The Hepatic dulness is represented in black. The dotted line above, on the 
Tight side, shows the position of the upper part of the liver, and therefore of the 
vault of the diaphragm deep within the thorax. Just outside the right nipple 
line, at the edge of the ribs, the little excrescence marks the position of the 
Gall-bladder. 

The Stomach is indicated partly by dotted and partly by continuous line. The 
area of stomach resonance lie3 between the dotted line on the left side and the 
margin of the costal arch. 

The anterior part of the Spleen and Kidney are indicated in black. 



THE LUNGS. PERCUSSION. 37 

correspond. For example, the surface-markings 
of the heart enclose a space (the cardiac area), 
which is small compared with the real size of the 
heart [fig. 10), but it is of the greatest importance 
for the reason that, so long as the organs in 
immediate relation with the heart are normal, the 
space varies in size and shape in direct proportion 
with any change in the heart itself. 

The medical landmarks and anatomical boun- 
daries are therefore not the same thing, and though 
closely related must not be confused one with .the 
other. 

The Boundaries of the Lungs. 

The lungs are in close contact with the ribs 
along their whole length. 

These are, therefore, their natural External 
Boundaries. 

The apex of each lung rises as a blunt cone 
into the neck as far as an inch and a half above 
the clavicle. The curved line, which corresponds 
with the apex and sides of this cone, can be easily 
percussed out, and gives the Upper Boundary. 

The edges of the lungs approximate anteriorly 
beneath the manubrium sterni, and come in con- 
tact at a point corresponding with the junction 
of the second costal cartilage with the sternum ; 
they remain in close approximation down as far 



38 HOW TO EXAMINE THE CHEST. 

as the level of the fourth, costal cartilage. From 
this point the anterior margin of the right lung 
continues onward down to the bottom of the 
sternum, sloping slightly away to the right side, 
while that of the left bends sharply away to the 
left side, to a point about two inches and a half 
from the bottom of the sternum. This leaves a 
roughly triangular space between the two lungs, 
in which part of the pericardium is uncovered. 
It corresponds with the area of cardiac dulness. 
(q.v.). 

The Middle Boundary cannot be determined by 
percussion for this reason. The sternum is a 
solid bone, which lies for some distance in close 
relation with the lungs. When, then, it is per- 
cussed, even in a part, where only solid structures 
lie beneath, as under the upper part of the manu- 
brium, or under the lower part over the heart, the 
vibrations are transmitted to those parts which 
lie over the lungs, and so to the lungs themselves, 
and, in consequence, the note in any part of the 
sternum will be equally resonant. 

The Lower boundary is of course the diaphragm, 
but this is too thin to define by percussion, so 
that we can determine its position only by means 
of the organs in relation with it ; these are, the 
liver, the stomach, and the spleen. Two of these 
organs, the liver and the spleen, are solid bodies, 
and will give, therefore, a non-resonant sound. 



THE LUNGS. PEKCUSSION. 39 

The stomach contains air, and will, therefore, give 
a resonant sound. 

Percussion will enable us, then, to determine 
where these organs are, and in this way where 
the diaphragm is. On the right side the termi- 
nation of the lungs will be marked by a line 
of non-resonance, or dulness, corresponding with 
the liver, and on the left side by a line of altered 
resonance corresponding with the stomach, and 
by a line of dulness corresponding with the 
spleen. 

Before, then, we can determine how large the 
lungs are we require to know what the upper 
boundaries of the liver, stomach, and spleen are 
in health, i.e. the surface-markings corresponding 
with these organs.* 

The Surface-Markings of the Liver. 

If a piece of string be taken and one end of it 
be placed upon the apex of the heart, i.e. in the 
fifth left intercostal space, one inch inside the 
nipple line, and the rest be carried almost hori- 
zontally, but with a slight inclination downwards, 
round the right side of the chest to the spine, 
this will represent the surface-marking usually 

* In ordinary respiration. the lungs do not quite come up to 
the edge of the pleura ; the small space left is called the com- 
plemental space. 



40 HOW TO EXAMINE THE CHEST. 

described as the Upper Boundary of the Liver. 
Tt will correspond, in the right nipple line, with 
the upper border of the sixth rib, and, as the 
ribs are curved downwards, it will cut the eighth, 
ninth, and tenth ribs as it passes backwards. 

This line marks the limit of absolute dulness, 
for, as the liver rises anatomically above this line 
deeper in the chest, forcible percussion will give 
a note of impaired or defective resonance, often 
as much as an inch higher. 

This is the normal position during ordinary- 
respiration, when the chest is moderately dis- 
tended with air, and the breathing quiet. It may 
be about an inch higher on forced expiration, or 
an inch lower on forced inspiration ; this line is 
the same whether the patient be standing erect or 
lying upon the back. 

While speaking of the liver it will be conve- 
nient to complete the description of the hepatic 
area. 

The greater part of the right lobe of the liver 
is concealed under cover of the ribs on the right 
side, and part also of the left lobe is beneath the 
ribs on the left side {fig. 10). In the epigas- 
trium part of the right lobe and part of the left 
are exposed, with the notch, which usually lies 
almost in the middle line, about half way between 
the umbilicus and the junction of the sternum 
with the xiphoid cartilage. 



. THE LUNGS. PERCUSSION. 41 

The liver passes under cover of the ribs on the 
right side just in the nipple line. This corre- 
sponds usually with the tip of the eighth costal 
cartilage. 

The Lower Boundary of the liver, then, on the 
right side, is continuous posteriorly with the edges 
of the costal arch, and conies out from under the 
ribs in the right nipple line. It then extends 
across the abdomen in a double curve, inter- 
rupted by the notch to the apex of the heart 
(fig. 10). 

As the anterior part of the liver overlaps the 
stomach and transverse colon, the transmitted 
resonance makes it generally very difficult to 
ascertain exactly by percussion the lower border 
of the liver, and it is usually more easily fixed by 
palpation. 

The liver is most conveniently measured in the 
nipple line. In this line the Upper Boundary 
should be at the level of the upper border of the 
sixth rib, and the Lower should cut the margin 
of the costal arch. Just outside this part (i.e. at 
the tip of the ninth rib) is the position of the 
gall-bladder. 

The vertical measurement of the hepatic dul- 
ness in the nipple line is, in the adult, on the 
average four inches. 



42 



HOW TO EXAMINE THE CHEST. 



Fig. '11. 




Diagram showing the normal boundaries of the lungs. 



THE LUNGS. PERCUSSION. 46 

The Surface-Markings of the Spleen. 

The Splenic Area is roughly oval in shape, and 
dull on percussion. It extends along the tenth 
rib as its long axis, from the posterior axillary 
line, forwards and downwards, for about two 
inches and a half. Its transverse diameter 
reaches above to the ninth rib, and below to the 
eleventh rib. 

This area cannot, however, always be dis- 
tinctly made out in adults. It is more easily 
determined in children. This is due probably to 
the fact that the ribs are softer and less rigid, 
and do not, therefore, transmit the resonance so 
readily from the adjacent lungs. 

The Surface-Markings of the Stomach. 

The area of Stomach Resonance (Traube's zone) 
extends from the apex of the heart (i.e. the edge 
of the left lobe of the liver) to the tip of the 
tenth rib. 

It is semicircular in shape, the diameter being 
the edge of the ribs, and measuring about six 
inches. Its depth is about three inches. 

The stomach extends, of course, much farther 
than this, across the epigastrium, beneath the 
margin of the liver {fig. 10), and, like the 
colon, which lies in immediate relation with it 



44 HOW TO EXAMINE THE CHEST. 

below, will give a resonant sound there, but it is 
only the limited area described above, which, in 
the examination of the chest, is spoken of as the 
area of stomach resonance. 

The boundaries of the stomach and spleen are 
not so constant, or so easy to determine, as those 
of the liver, but they are also not of so much 
importance, for the liver reaches so far to the left 
side, that its boundaries, taken in conjunction 
with the cardiac dulness, are enough to fix, with 
sufficient accuracy for ordinary purposes, the size 
of the left lung. 

We have now ascertained the position of the 
diaphragm, and we know, that all that is above 
this should be occupied by lung, except in the 
mediastinum, where the heart and great vessels 
lie. In health we need consider nothing but the 
heart, for the rest of the mediastinum gives, as 
the lungs do, a resonant note on percussion. 

The Area of Cardiac Dulness is roughly tri- 
angular in shape, and corresponds with the space 
exposed by the left lung as it recedes from the 
right. It is represented on the diagram, (q. v), 
and will be found fully described later. 

The Surface-Markings of the Lungs. 

These are as follows : 

The Upper. A curved ]ine, the apex of which 
reaches one inch and a half above the clavicle. 



THE LUNGS. PEKCUSSION. 45 

The Anterior. 

(a) On the Right Side, the middle line of the 
sternum, from the level of the second costal carti- 
lage to the base of the xiphoid cartilage. 

(b) On the Left Side, the middle line of the 
sternum, from the level of the second to the level 
of the fourth costal cartilage, and thence to the 
apex of the heart. 

The Lower. 

(a) On the Eight Side, the upper border of the 
liver. 

(b) On the Left Side, a line drawn from the 
apex of the heart along the upper border of the 
stomach resonance and the splenic dulness. 

The Posterior. 

1. A Vertical Line drawn on each side one inch 
from the dorsal spine. 

2. A Horizontal Line drawn outwards on each 
side from the eleventh dorsal spine. This, on 
the right side, is continuous with the upper 
boundary of the liver. 



ALTERATIONS OF BOUNDARIES. 

In disease the lungs rarely remain of their 
normal size. They are either larger or smaller 
than they ought to be. These changes, though 
generally evident on inspection and palpation, 



46 



HOW TO EXAMINE THE CHEST. 



Fl9. 12. 



\U 




Diagram showing in dark line the actual boundaries of the 
lungs in a well-marked case of emphysema, and in dotted line 
the normal boundaries. 



THE LUNGS. PERCUSSION. 47 

are most distinctly indicated by alterations in 
the boundary lines. 

The diaphragm is freer to move than any part 
of the thoracic walls, and changes in its position 
are often among the earliest evidences of changes 
in the lungs. This can be recognised only by 
percussion. Hence the importance of deter- 
mining as early as possible in our examination 
of the chest the position which the diaphragm 
occupies. 

Symmetrical Changes. 

Where the lungs are Symmetrically Enlarged, 

as in the disease called emphysema, there may or 
may not be visible enlargement of the thorax, 
but there will always be displacement of the 
diaphragm. The diaphragm will stand lower 
than it ought, often a whole interspace too low. 
The cardiac area will also be smaller than it 
should be ; for the lungs, as they enlarge, cover 
up that part of the prsecordiuni which, in the 
ordinary condition, is exposed. 

The percussion signs, then, of emphysema 
show displacement downwards of the diaphragm, 
and diminution in size, or absence of the cardiac 
dulness. 

Where the lungs are Symmetrically Contracted, 
as often happens in old age (senile emphysema), 



48 



HOW TO EXAMINE THE CHEST. 




Diagram showing the boundaries of the lungs in a case of 
bilateral contraction of the lungs (senile emphysema). 
The white dotted line shows the normal boundaries. 



THE LUNGS. PERCUSSION. 49 

the diaphragm will stand at a higher level than 
normal. It may be a whole intercostal space 
too high, and, in like manner, the praecordium 
will be more uncovered than usual, and the area 
of cardiac dulness larger than normal. 



Unsymmetrical Changes. 

If the changes be limited to one side, the 
diaphragm on that side will be displaced. If 
lung on that side be larger, the diaphragm will 
stand lower, if smaller, it will stand higher. 

Where a part of one lung is contracted, as 
after pleurisy, or where a large cavity has formed 
in it, the opposite lung, if it has remained 
healthy, often undergoes compensatory enlarge- 
ment. This has received the name of Compen- 
satory Hypertrophy* As the one lung is much 
smaller, and the other much larger, than it 
ought to be, we shall have evidence of a great 
dislocation of the boundaries as is shown in 
fig. 14. 

A similar extreme dislocation of boundaries is 
seen in cases where one pleural cavity is greatly 
distended with air, as in pneumothorax (Jig. 15), 

# This is also spoken of as compensatory emphysema, but, as 
there is no true emphysema, this term is misleading, and should 
not be used. 

4 



50 



HOW TO EXAMINE TEE CHEST. 



Fig. 14. 




Diagram showing the displacement of the boundaries in a 
case of contraction of the left lung, with compensatory hyper- 
trophy of the right. 



THE LUNGS. PERCUSSION. 51 

or with fluid, as in pleuritic effusion {fig. 16). 
In these cases, not only is the diaphragm pushed 
down as far as it can go, so as to become 
sometimes even concave instead of convex above 
and to project below the ribs, but the lateral 
boundaries are also dislocated far over towards 
the unaffected side. 

This we determine by an extension beyond the 
sternum, in the one case {'pneumothorax) of the 
area of resonance, and in the other {pleuritic 
effusion) of the area of dulness. 

In cases of pneumothorax, however, in which 
there is free communication between the air inside 
the pleura and that outside the body, either 
by a large opening through the chest-walls or 
through the lung, and where, consequently, 
there is no distension of the pleura, i.e. no pres- 
sure in the pleura, there is still considerable dis- 
location of boundaries. 

This is due to the elasticity of the lungs, the 
lungs on each side contracting, and that on the 
sound side dragging over towards itself the 
mediastinum and the organs in it. 



VAKIETIES OF PERCUSSION SOUND. 

Hitherto we have considered percussion only as 
the means of determining the size of the lungs, 



52 HOW TO EXAMINE TEE CHEST. 



Fig. 11 




Diagram showing the displacement in a case of pneumo- 
thorax of the left side. 



THE LUNGS. PERCUSSION. 53 

we must now consider how it enables us to deter- 
mine the conditions in which, the lungs are. 

Wherever the lungs are, the percussion note 
should be resonant. The amount of resonance 
will vary within wide limits, even in health, in 
different individuals. It will depend in great 
part upon the amount of skin, fat, and muscle 
which covers the ribs, i.e. upon the thickness of 
the walls of the thorax, and will therefore be less 
in fat than in thin people. Even in a perfectly 
healthy chest the resonance varies in different 
parts, being greatest in the axilla where there is 
least to interfere with the percussion sound. 

But, making allowance for all this, the reso- 
nance may be greater or less than it ought to be. 
In emphysema, where the vesicles of the lungs 
are dilated and the walls thinned, where, there- 
fore, there is relatively more air and less solid in 
the lung, the note becomes deeper, more hollow- 
sounding, more drum-like. This is called Tym- 
panitic Resonance, and resembles the note which 
may be normally obtained on percussing over the 
stomach. 

A variety of tympanitic percussion is not un- 
common in cases, where air-containing lung tis- 
sue intervenes between the chest-walls and some 
solid mass more deeply seated, as, for instance, 
deep-seated pneumonia, or a tumour, or even 
occasionally fluid effusion in the pleura. 



54 HOW TO EXAMINE THE CHEST. 




Diagram showing the displacements produced by a large 
effusion into the right pleural cavity. 

The black area represents the absolute dulness of the fluid 
The heart is displaced so that the apex is outside the left 
nipple line. The liver is depressed and twisted, so that the 
notch is nearly under the margin of the left costal arch 
instead of being in the middle line. 

The white line indicates the probable position of the upper 
border of the liver on the right side, and of the edge of the 
right pleura on the left side. 



THE LUNGS. PERCUSSION. 55 

It is probably due to the relaxation of the 
lung tissue, i.e. the loss of its normal tension and 
tone above the parts diseased. 

A similar hyper- resonance is not rare in acute 
fevers, and has probably the same causation and 
explanation as that loss of tone in the intestines, 
which gives rise, under similar conditions, to 
tympanites. 

For the opposite condition, in which there is 
less air and more solid relatively in the lung, 
there is no distinctive name, but the percussion 
resonance is spoken of as Impaired or Deficient. 

Many other varieties of resonance have been 
described and various names given to them, but 
they are not really required in actual practice. 

For ordinary purposes the following four terms 
are all that are necessary : 

1st. Tympanitic. 

2nd. Normal. 

3rd. Impaired.* 

4th. Dull. 

One other named variety of abnormal percus- 
sion sounds must be referred to. This is the 
Cracked-pot Sound (bruit de pot f ele) . This is a 

* Boxy is a term often used. The term conveys much what 
the sound of percussion suggests. It is as though we were per- 
cussing an air-containing chamber with dense and rigid walls 
like a box, and it corresponds frequently with such a condition, 
pathologically. 



56 HOW TO EXAMINE THE CHEST. 

jarring or jangling sound, like that produced 
when a cracked china bowl is struck. 

It is not uncommon in cases of phthisis over 
superficial cavities in the lung, and it is best 
elicited by forcible, sharp percussion, the patient 
having the mouth wide open and breathing 
quietly. It is not constant in phthisis, nor is it 
by itself any sign of disease of the lungs, for it 
is not rare in children with healthy chests, 
and may be produced in adults sometimes, where 
air-containing lung tissue lies between the chest- 
walls and some solid mass, either a patch of pneu- 
monic consolidation, a tumour, or occasionally 
even an enlarged heart;. 

It is supposed to be due to the sudden forcing 
out by percussion of a stream of air from a por- 
tion of the lung into the bronchial tubes, and can 
be imitated fairly well by clenching the palms of 
the hands loosely together, and striking them 
sharply upon the knee. 

Want of Symmetry on Percussion, 

Fortunately, it is not for the most part an 
increase or a decrease in tone, as compared with 
an ideal typical standard, which we have to 
recognise, but, as on inspection and palpation, 
so also on percussion, it is for a want of symmetry, 
i.e. for a difference between corresponding parts on 



THE LUNGS. PERCUSSION. 57 

the two sides, that we look as evidence of disease. 
If, in symmetrical parts of the chest, the percus- 
sion resonance is not also symmetrical, but there 
is a difference between the two sides, it is cer- 
tain that some change has occurred in the parts 
beneath. 

The only place in health in which want of 
symmetry is observed, with the exception of the 
cardiac area, to which reference has been already 
made, is at the right apex. There the lung is 
thicker, stumpier, and is more encroached upon 
by the large vessels than on the left side. Con- 
sequently, there is often a slight impairment of 
percussion here, as well as also, on palpation 
and auscultation, a slight increase in the amount 
of the vibrations of the voice and of the breath 
sounds. 

The difference is, however, slight, and the 
same amount of difference on the left side would 
be evidence of disease. It is necessary to refer 
to this, although it is not likely to create difficulty 
in ordinary cases. 

Wherever the percussion note is unsymmetrical, 
there is, with the previously mentioned excep- 
tions, some change in the condition of the part 
beneath, namely, in the lungs or in the pleura. 

Under auscultation we shall learn how to 
determine which of these it is. 

For the present it is sufficient to note that by 



58 HOW TO EXAMINE THE CHEST. 

means of percussion we can establish, two sets of 
most important facts about the lungs. 

1. Their extent and their relation to adjacent 
organs. 

2. Their condition, whether healthy or not. 



THE LUNGS. PERCUSSION. 



59 



SYNOPSIS. 



On percussing a chest, it is most important to 
proceed systematically. 

1st. We must determine the actual boundaries 
of the lungs, mark them carefully, and compare 
them with those, which, we know, ought to be 
found in health. 

2nd. We must percuss the symmetrical parts 
of the chest in order, from above downwards, 
comparing one side with the other ; 

1. The supraclavicular 
regions ; 

2. The clavicular re- 
gions ; 

I. In front, <J 3. The subclavicular re- 

gions ; 

4. The mammary and 
infra-mammary re- 
gions ; 

5. The axillary regions ; 

6. The suprascapular re- 
gions ; 

7. The infrascapular re- 
gions ; 

The interscapular 
spaces, 
symmetrical, the lungs and 
pleura are probably healthy. If not, we shall 
then proceed to ascertain what is wrong by 
further examination. 



II. Laterally, 



III. Posteriorly, ^ 



If these be all 



L 



60 HOW TO EXAMINE THE CHEST. 



AUSCULTATION. 

Under this head we place all facts, which we 
can ascertain by placing the ear upon the chest, 
and listening to the sounds produced. These 
are of two kinds. 

1. The sounds produced by breathing. 

2. The sounds produced by the voice. 

Apparatus. 

For the purposes of auscultation apparatus is 
not generally necessary, though it is convenient. 

Stethoscopes (stethos the chest, skopein to 
examine) have been devised of all kinds, some 
solid, some hollow, and made of metal, wood, 
ivory, or other substances, of various sizes and 
shapes. Habit will accustom us to all, and, 
except for convenience, we might do without 
any. 

The stethoscopes in use at present are of two 
kinds, the single, for one ear, and the double, 
for both ears, the binaural. 

It is best to commence with the single stetho- 
scope. 

The single stethoscope consists of a cylinder, 



THE LUNGS. AUSCULTATION. 61 

usually of some tough or light wood, six or eight 
inches in length, with a broad, flat end on which 
to place the ear, and a narrow end to be placed 
upon the chest. It is usually • perforated by a 
hole running from end to end {fig. 17). 

In chosing a stethoscope the chief points are 
these : — The broad part should be of such a size 
and shape that the ear may rest comfortably 
upon it. The small end should not be more than 
about three quarters of an inch in diameter. It 
should have broad, flat, and rounded edges, so 
that it may not pinch or cut the skin, when it is 
placed upon it. 

Let us suppose, that we are going to examine 
the chest with the left ear. 

The stethoscope is taken in the right hand near 
its small end, and placed upon the part we wish 
to examine, so that this is everywhere close upon 
the skin, care being taken that nothing is ir 
contact with the stethoscope or moving upon the 
walls of the chest. The chest, if possible, should 
be bare. 

The left hand is laid upon the shoulder or back 
of the patient, and the left ear placed upon the 
ear-piece of the stethoscope. The right hand 
may then be taken away, and the stethoscope 
will be supported between the ear and the chest. 
No more pressure should be exercised than is 
required to keep the stethoscope in position. 



62 HOW TO EXAMINE THE CHEST. 

The hand upon the shoulder will keep the 
patient steady and will preven^he exercising 
of more pressure upon the stethoscope with the 
head, than is necessary to keep it in its place. 

In examining a patient, it is most important to 
be in a comfortable position, otherwise the patient 
will be probably uncomfortable also. 

Fig. 17. 





The single stethoscope. 

Binaural stethoscopes are now much used 
{fig. 18). They are convenient especially for the 
examination of patients in bed, but they are not 
the best to begin with, as it is difficult at first 



THE LUNGS. 



AUSCULTATION. 



63 



to distinguish the sounds produced in the stetho- 
scope, from those produced in the lung, and they 
have this practical disadvantage, that the chest- 
piece must be placed directly upon the skin, for 



Fig. 18. 





Binaural stethoscopes. 



even a covering of thin gauze is sufficient to inter- 
fere greatly with the transmission of the sounds. 
The differential stethoscope, in which there are 
two chest-pieces with separate tubes, is not much 



64 HOW TO EXAMINE THE CHEST. 

employed at present, and has, I think, no special 
advantage. 

The simplest instrument is the best to begin 
with, and we shall use the single stethoscope 
such as is shown in fig. 17. 



THE AUSCULTATION OF TEE VOICE. 

We will deal with the voice sounds first, 
because they are less difficult to explain. 

Vocal Resonance. 

The vibrations of the voice are produced in the 
larynx and mouth ; the musical note at the vocal 
cords, the words in the mouth and pharynx. 
The vibrations are propagated thence in all direc- 
tions—outwards through the mouth, and back- 
wards along the trachea and bronchial tubes. It 
is well to select some simple sound for the patient 
to produce, and to use it constantly, such as the 
long vowel "ah!" or a repetition of the same 
sound, as in " ninety-nine." 

When now the stethoscope is placed over the 
larynx, and the patient speaks, we hear the voice- 
sounds with an intensity which is almost painful. 
If the stethoscope be placed lower down upon the 
trachea, we hear them less loudly, and over the 



THE LUNGS. AUSCULTATION. 65 

alveoli of the lung, though still audible, they are 
much diminished in intensity, have lost their 
clearness and sharpness, and have become hum- 
ming or muffled. 

To the vibrations of the voice which we hear 
the name Vocal Resonance is given, to distinguish 
them from the vibrations which we feel, and which 
are called vocal vibrations. 

Vocal vibrations we feel (Palpation) . 

Vocal resonance we listen to (Auscultation) . 

Varieties of Vocal Resonance. 

The vocal resonance over the vesicles of the 
lung receive the name of pulmonary, muffled, or, 
better, Vesicular resonance. Over the larynx it 
is called Laryngeal, and over the trachea Tracheal, 
while that which is intermediate between tracheal 
and vesicular is called Bronchial, and bears also the 
name Bronchophony (phone, voice). 

These terms are purely conventional and do 
not admit of accurate definition. 

The classification is anatomical, and as the 
trachea, for example, passes into the bronchi on 
one side and the larynx on the other, so will the 
varieties of tracheal resonance pass insensibly 
into bronchial or laryngeal. 

By laryngeal, tracheal, bronchial, and vesicular 
resonance, therefore, is meant resonance of such a 

5 



66 HOW TO EXAMINE THE CHEST. 

kind as is heard in health over these parts re- 
spectively of the respiratory tract, and, when 
these terms are used in reference to disease, it is 
not meant, that we have necessarily an entirely 
new sound such as is never heard in health, but 
that sounds, which in health ought only to be 
heard in particular places, are in disease heard 
somewhere else, where they ought not to be heard. 
The sounds of disease are for the most part not 
so much abnormal sounds, as normal sounds heard 
in abnormal places. 

Fortunately it is not so much the name we 
give to these sounds, as the fact itself, which is 
important for the purposes of diagnosis. 

If, where we should only hear vesicular reson- 
ance, we do not hear it, but some other kind of 
resonance, whatever name we call it by, we know 
the lung to be in an abnormal condition. 

The vibrations of the voice are carried, not by 
the walls of the tubes, but by the air within them. 
This we know to be the case, because, when the 
column of air is broken by either a foreign body 
sticking in a bronchus or by the tubes being filled 
with mucus, we find that the vocal resonance is 
lost in the corresponding part. 

Every time these tubes divide the vibrations 
are in part dispersed and lost, and where they 
finally split up into the numerous vesicles of the 
lungs, this dispersion becomes so great that but 



THE LUNGS. AUSCULTATION. 67 

little of tlie original vibrations is left to pass on to 
the walls of the chest. 

How much the alveolar tissue of the lung is 
capable of diminishing sound is clearly demon- 
strated in the case of emphysema, where the 
enlarged lung comes forward and covers up the 
heart, muffling the heart sounds* to such an 
extent as to make them almost inaudible. 

Hardly anything can muffle sound better than 
a pillow, though the actual amount of solid sub- 
stance it contains is small. The conditions are 
much the same in the lungs, viz. relatively large 
air spaces separated from each other by thin, 
irregular septa (the feathers) . 

The amount of vocal resonance differs much in 
different individuals. This depends in chief 
measure : 

1st. Upon the loudness of the voice, i.e. the 
amount of sound produced : 

2nd. Upon the depth of the voice, for the 
deeper the voice is, the coarser are the vibrations ; 
hence in women and children they will be more 
difficult to hear (as they are also to feel) than in 
men : 

3rd. Upon the thickness of the walls of the 

* It is not uncommon under these circumstances for a dia* 
gnosis to be made of a weak heart, though the cause of the 
weak heart- sounds lies not in the heart but in the lungs. 



68 HOW TO EXAMINE THE CHEST. 

cliest. Thus the vibrations are often difficult to 
detect in very fat people, or where the skin is 
cederuatous, &c. 

"When the vocal resonance is listened to over 
a portion of consolidated lung, the vibrations are 
sometimes carried with unusual distinctness along 
the stethoscope into the ear, so that not only the 
vibrations of the voice, but even the words, are 
very distinctly audible. This is called Pectori- 
loquy or Direct Vocal Resonance. It is a variety of 
bronchophony. 

In bronchophony there is an increase in the 
transmission of the voice or vocal sounds. In 
pectoriloquy of the speech or articulate sounds. 

"When the lungs are consolidated, or where 
there are large cavities in them, the Heart 
Sounds, like the vocal vibrations, are often earned 
with unusual loudness to the ear, and we speak 
of them as unduly audible. 

In children The Cry is as useful as the voice in 
adults, and the same changes in resonance occur 
in it. 

Often, instead of speaking out loudly, the 
patient is made to whisper. The Whisper Sounds 
undergo changes similar to those of the vocal 
sounds. They may be diminished or increased. 
Thus, we speak of Bronchial Whisper or Whisper- 
ing Bronchophony, of Whispering Pectoriloquy, 
and of Cavernous or Amphoric Whisper. 



THE LUNGS. AUSCULTATION. 69 

It lias been stated that whisper sounds provide 
an easy means of distinguishing between an 
effusion of pus and an effusion of serum into the 
pleural cavity, the whisper sound being distinct 
when the effusion is serous, and absent when it 
is purulent. This is not correct. 

When the stethoscope is placed over a part of 
the chest where the lung is solid, and the observer 
speaks, the resonance of his own voice is some- 
times loudly heard in the ear which rests upon 
the stethoscope. This has been called Auto- 
phony {Autos, own; phone, voice). Its exact 
physical causes are not understood, but it is, so 
far as is known, only met with over consolidated 
lung. 

It remains to speak only of one other term often 
used, viz. iEgophony. This is a peculiar tremu- 
lousness, which is added to the vocal vibrations, 
and which has been compared to the bleating of 
a goat, whence the name was taken. It is heard 
in cases of moderate pleuritic effusion at the 
upper level of the fluid, and usually only poste- 
riorly at the inferior angle of the scapula. Occa- 
sionally a somewhat similar tremulousness is 
heard just above pneumonic consolidation at the 
base of the lung. 

iEgophony is supposed to be due to the irre- 
gular conduction of vocal vibrations through 
lung tissue which is irregularly compressed and 



70 HOW TO EXAMINE THE CHEST. 

collapsed, as it lies just above the fluid. This 
sound is of doubtful practical importance. 



THE SOUNDS OF BREATHING. 

What has been said of the sounds of the voice 
is true also to a great extent of the sounds of 
breathing. 

If the stethoscope be placed upon the larynx 
and the patient breathe in and out, sounds will 
be heard both on inspiration and on expiration. 
These sounds are produced in great measure like 
the sounds of the voice by vibrations set up in 
and round the glottis, and like them they travel 
in all directions, outwards through the mouth 
and inwards towards the lungs, and as they 
travel backwards they will be progressively 
diminished in intensity, until over the vesicles 
but little of them is heard. 

Now, if we compare the breathing over the 
larynx with that over the vesicles, we shall 
notice that not only is there a difference in loud- 
ness, but that there is also an alteration in 
character. 

The Sounds at the Larynx are clear, harsh, and 
double ; both inspiration and expiration are loud, 
and equal in loudness and duration. 

Over the Vesicles the sound is feebler and has 



THE LUNGS. AUSCULTATION. 71 

lost its clear character. It has become, like the 
voice sounds, muffled, and instead of two sounds 
one only is audible. Expiration is absent, or if 
not entirely absent, is only to be heard faintly and 
with difficulty. 

As in the case of the voice sounds so with the 
breathing sounds a classification can be made 
into 

Laryngeal. 
Tracheal. 
Bronchial. 
Tubular. 
Vesicular. 
Again, this is a purely anatomical classification, 
and we mean by these terms, when we are 
speaking of disease, that the respiratory sounds 
audible resemble those heard in health either in 
the larynx, trachea, bronchi, smaller tubes, or 
vesicles. 

If we are in doubt what name to give to 
a particular kind of breathing we should com- 
pare it with that heard over different parts of 
the respiratory tract, and give it the name of 
that part to which it bears the greatest resem- 
blance. 

Stridor is a peculiar variety of laryngeal or 
tracheal breathing. It is pathognomonic of 
narrowing or constriction of some part of these 
tubes. It is a loud, harsh, see-saw, double 



72 



HOW TO EXAMINE THE CHEST. 



Fig. 19. 




Shows the position of the trachea and bronchi behind. 
The circles mark the spots where bronchial breathing is often 
heard in a healthy chest. 



THE LUNGS. AUSCULTATION. 73 

grating sound, audible at a distance from the 
patient and associated usually with dyspnoea. 
The cough in these cases is also usually croupy, 
or as it is called brassy. The constriction is most 
commonly produced by the direct pressure upon 
the trachea of an aneurysm or tumour, but it may 
have its seat in the larynx in consequence of 
local changes there, as in croup in children, or 
in stenosis or tumour in the adult. 

The larynx and trachea are superficial but the 
bronchi are deeply placed. Bronchial breathing 
may sometimes be heard normally in front under 
the first piece of the sternum, and behind either 
upon the second dorsal spine or right and left of 
the spine an inch or two lower in the interscapular 
spaces {fig. 19). 

Vesicular breathing is soft and muffled in 
character, and consists almost entirely of an 
inspiratory sound, expiration being either quite 
inaudible, or very faint. 

The sound is made up of two parts. 

1. The sound which is conducted along the 
bronchi and smaller tubes and modified by having 
to pass through the vesicles. 

2. A sound produced in the vesicles by the 
air as it passes into them from the small air 
tubes. 

Whatever explanation is given of its produc- 
tion, the sound itself is characteristic. 



74 HOW TO EXAMINE THE CHEST. 

What it is, however, cannot be taught by 
description. It must be learnt by observa- 
tion. 

Vesicular breathing is,, as has been said, 
marked off from all other kinds by the absence 
or great enfeeblement of the expiratory sound. 
If this be faintly audible, we approach the kind 
to which the name tubular is given. If it be as 
loud and long as inspiration and have a high 
harsh pitch, such as we hear occasionally over 
the bronchi at the places named, we should call 
it bronchial. 

In bronchial breathing the sound resembles 
that produced by the mouth when placed in the 
position to pronounce the guttural " ch." 

In tracheal breathing the sounds, both of 
expiration and inspiration, approach more nearly 
" ah/' and in laryngeal " au." 

Cavernous and amphoric breathing are not 
audible anywhere in health. They approximate 
in character to the laryngeal sound, but have in 
addition a greater hollowness, and, in the case 
of amphoric breathing, certain superadded semi- 
musical (consonant) sounds, such as those heard 
on breathing into a jug (amphora), from which 
the name is taken. 

Sometimes the breathing sounds over the 
vesicles are normal, so far as their character 
goes, i.e. they are vesicular, but their rhythm is 



THE LUNGS. AUSCULTATION. 75 

altered. They have become jerky, interrupted 
(Saccadee), wavy. 

The cause of this alteration of rhythm may 
vary. 

It may be due to irregular action of the muscles, 
either in consequence of some change or defect 
in the muscle itself, or, as is more common, in 
consequence of irregular nervous action. Hence 
it is very common in nervous and hysterical 
patients. 

Or its cause may lie in the lung itself, and be 
due to imperfect and irregular expansion of the 
lung tissue. Hence it is often met with in the 
early stages of consolidation of the lung. 

Such alterations in the rhythm of respiration 
are usually unsymmetrical and are to be dis- 
tinguished from those symmetrical abnormalities 
which are due to irregular respiratory movements 
as in sobbing, sighing, coughing, &c, in which 
the whole rhythm may be much altered, through 
the action of the nerve centres as in Cheyne- 
Stokes breathing (q.v.). 

Variations in the breathing sounds depend 
upon the same conditions as those of the voice 
sounds. 

Energetic breathing increases the loudness, 
and if it be violent, we often get over the vesicles 
both inspiration and expiration audible. This 
has received the name of " puerile breathing," 



76 HOW TO EXAMINE THE CHEST. 

because it is so commonly heard in children, 
even with perfectly healthy chests. It corre- 
sponds very closely with the tubular breathing 
previously described. 

By some authors bronchial is used as a general 
term, to mean simply that the breathing sounds 
are altered from health, and are exaggerated or 
increased. This double use of the term produces 
great confusion. Bronchial is by most writers 
used in its anatomical signification as it has been 
here described, to signify a particular kind of 
altered breathing which is very characteristic. 

This is the only reasonable use of the term. 
If the mere fact that the breathing sounds are 
altered or exaggerated has to be expressed with- 
out specifying in what particular respect, for the 
sake of clearness it is best to say so simply, and 
to use the term " altered " or cc exaggerated," 
which states general facts and leads to no mis- 
understanding. 

It is quite unnecessary to construct minute 
definitions of the various terms used. The only 
intelligible interpretation is the anatomical one, 
and it would be well to agree to use the terms 
only in this sense, recognising that as the parts 
of the respiratory tract pass without distinct 
limitation into one another, so, too, will the 
varieties of respiratory sounds. 

It is good, however, to retain these separate 



THE LUNGS. AUSCULTATION. 77 

terms as indicating roughly the amount and kind 
of change which the lung has undergone. 



USE OF THESE FACTS IN DIAGNOSIS. 

Let us inquire now what use we can make of 
these facts for the purpose of diagnosis. 

The sounds produced at the larynx, whether 
by the voice or by breathing, are transmitted, as 
we have said, almost entirely by the air column 
in the trachea, bronchi, and smaller tubes to the 
vesicles of the lungs. They then cross the two 
layers of the pleura to reach the chest walls, and 
through these are conducted to the ear. 

Along their whole course they are progres- 
sively diminished; 

1st. Every time that the air-tubes divide, and 
especially by their terminal expansion into the 
vesicles ; 

2ndly. As the vibrations pass from the vesicles 
to the pleura and chest walls, and thence along 
the stethoscope to the ear. 

We may regard all these parts, viz. the air- 
vesicles, the pleura, and the chest walls as so many 
obstructions placed in the way of the vibrations. 

Any alteration in these parts will change the 
transmissibility of the vibrations. It may make 
them more easily or less easily heard, and we 



78 HOW TO EXAMINE THE CHEST. 

shall speak then of the voice or breathing 
sounds, 

1. As Increased, i.e. more intense than normal, 

2. As Diminished, ~\i,e. less intense than 

3. As entirely absent, J normal, 

And lastly, as Modified {e.g. in aegophony) . 

If, for instance, the walls be very thick, as in 
fat persons, or where the subcutaneous tissue is 
cedematous, a greater obstruction will be offered 
to the vibrations, and they will be diminished. 

If we lay outside the walls of the chest several 
folds of cloth, we place a fresh obstruction in the 
way of the vibrations, and they are therefore 
diminished. 

If we take a water cushion and lay it upon the 
chest, the vibrations then cease to be audible, 
and become completely absent. The effect would 
be the same, if we could place the water cushion 
inside the chest walls, i.e. in the pleural cavity. 

In many forms of disease of the pleura this is 
exactly the condition which is produced. An 
effusion of fluid takes place into the pleural sac, 
and we have our water-bag inside the chest. 

In other cases the pleura itself becomes much 
thickened, but in both cases alike a fresh ob- 
struction is offered to the passage of vibrations, 
and they will be either much diminished or com- 
pletely absent. 

On the other hand, we have learnt that it is the 



THE LUNGS. AUSCULTATION. 79 

breaking up of the air-tubes into the vesicles of 
the lung which muffles most the vibrations in 
health, for they have to pass through a most 
heterogeneous body formed of numerous irre- 
gular air-chambers separated by thin septa, like 
a feather pillow. 

Suppose now, that this very heterogeneous 
body were made homogeneous by the substitu- 
tion for the air in the vesicles of some solid 
substance, we should do away at once with what 
we know to be one of the chief obstructions to 
the passage of vibrations. The other parts then 
remaining the same, the vibrations would reach 
the chest walls increased in intensity. 

This we find to be the case, and we have 
therefore an easy means of diagnosing between 
diseases of the two great structures belonging 
to the lung, viz. the lung itself and its pleural 
sac, for we have, in affections of the pleura one 
obstruction more, and therefore diminished pas- 
sage of vibration, and in solidified lung one 
obstruction less, and therefore increased trans- 
mission of vibrations. 

All that has been just said applies equally to 
the vocal resonance, the vocal vibrations, and 
the breathing sounds. 

If, then, we find in any part of the chest that 
the vocal vibrations, the vocal resonance, and 
the breathing sounds are increased, we may con- 



80 



HOW TO EXAMINE THE CHEST. 



elude that this is due to the lung in that part 
having become consolidated. If, on the other 
hand, we find the vocal vibrations, vocal reson- 
ance, and the breathing sounds diminished, we 
may infer that the pleura is affected. In both 
cases alike percussion will be either much im- 
paired or absolutely dull, because there is either 
but little air containing lung tissue or none at all 
in that part. 

Given then a part of the lung in which the 
percussion is impaired or dull, we are enabled by 
palpation and auscultation to determine, whether 
this dulness be due to an affection of the lung or 
of the pleura according to the following table : 



Table for the diagnosis between Disease of the 
Pleura and Disease of the Lung, 

Disease of the Pleura Disease of the Lung 

(e.g. fluid effusion). (e.g. pneumonic consolidation), 

Percussion dull. Percussion dull. 



Vocal vibrations ~| diminished 
Vocal resonance >• or 

Breathing sounds J absent. 



Vocal vibrations 

Vocal resonance > increased. 

Breathing sounds J 



As has been already stated the vibrations 
travel chiefly by the air in the tubes. If, then, 
by any chance the tubes become plugged, so that 
the continuity of the column of air is broken, the 
transmission of the vibrations will be prevented. 
This happens occasionally in pneumonic consoli- 



THE LUNGS. AUSCULTATION. 81 

dation where there is excessive secretion, and 
makes the diagnosis difficult; but the course of the 
case will remove all doubt. For, as the secretion 
is removed, the ordinary signs of consolidation 
will appear, 

NEW SOUNDS. 

We have hitherto spoken of sounds, the ana- 
logues of which may be heard normally in 
health. We come now to the class of sounds, 
which are heard only in disease. These fall into 
two groups, 

1. Those produced in the lungs, Pulmonary. 

2. Those produced in the pleura, Pleural. 

To the pulmonary sounds the name Rales was 
given by Laennec, who divided them into crepi- 
tant, mucous, and sonoro-sibilant'; the two first 
are more commonly called Crepitation, and the 
latter Rhonchus and Sibilus. 

These are the terms which we shall employ. 

Crepitation. 

Crepitation is produced by the bursting of air- 
bubbles in fluid, and it is spoken of as Large, 
Medium, or Small, according to the supposed size 
of the bubbles which produce it, the larger bub- 
bles giving rise to the louder sound. 

6 



82 HOW TO EXAMINE THE CHEST. 

Excellent crepitation is heard after washing the 
hands in warm water, as the little soap-bubbles, 
which form the lather, burst. This explanation 
has caused crepitation to be often spoken of as 
Moist sounds, in contradistinction to Rhonchus 
Sibilus, and which are called Dry sounds. 

One form of crepitation has probably a different 
explanation from that given above. This is called 
Fine Hair Crepitation, because it sounds like the 
crackling of the hair of the head or whisker when 
rubbed between the fingers over the ear. 

It is probably due to the crackling produced 
by the separation of the walls of the vesicles from 
each other by inspiration, when, as the result of 
collapse or pressure, they have been in partial 
contact. 

Crepitation similar in character, though prob- 
ably not produced in the same way, is also heard 
occasionally over emphysematous lungs. 

The noisy bubbling sounds, which are heard in 
the trachea of dying people, and to which the 
name of the " The Death Rattle " is given, are pro- 
duced, like the ordinary forms of crepitation, by 
the bubbling of air, as it passes through the 
mucus which has collected in the trachea. 

Rhonchus and Sibilus. 

Rhonchus and Sibilus are sounds often musical 
in character, produced by vibrations set up in 



THE LUNGS. AUSCULTATION. 83 

the air, as it passes through the bronchial tubes, 
the mucous membrane of which has been altered 
or roughened by inflammation or secretion. 

Rhonchus is produced in the large tubes and 
is deeper in tone. It is often described as snor- 
ing, cooing, or grating, according to the special 
characters of the sound. 

Sibilus is produced in the small tubes, and is 
wheezing and more hissing in character. 

One great peculiarity of rhonchus and sibilus is 
the rapid way in which they alter or occasionally 
temporarily disappear, as the mucus which has 
caused them is dislodged. A fit of coughing 
will often alter the character of the rhonchus 
and sibilus, as well as also the places where they 
are heard. 

Coughing affects also crepitation, occasionally 
removing it, when we may infer that it was pro- 
duced by a temporary accumulation of mucus in 
a small bronchus, or, as is usual, rendering it more 
evident, and sometimes producing it, where in 
ordinary respiration it is not audible. In every 
case, where it is at all likely that crepitation may 
be produced, the patient should be made to 
cough, while the chest is being examined and then, 
either during the cough or, as is more common, 
during the deep inspiratiop which follows ii, cre- 
pitation may be heard. 



84 HOW TO EXAMINE THE CHEST, 

Pleural Friction. 

The surfaces of tlie healthy pleura are smooth, 
and move upon each other during respiration 
without producing any sound. When the sur- 
faces are no longer smooth, but are roughened 
by disease, the rubbing of the two rough surfaces 
produces a sound, to which the name of Friction 
is given. 

The character of pleural friction differs much 
in different cases. Sometimes it resembles the 
creaking of a piece of dry leather when it is 
folded. This is called Dry-Leather Creaking. At 
other times it is distinctly rubbing in character. 

At other times the sound is hardly a rubbing 
sound, so much as a minute crackling, audible 
usually at the end of inspiration. 

This it is often very difficult to distinguish by 
the sound alone from the fine small crepitation 
produced in the lung. 

Characters of the Friction Sound. 

Friction, being produced in the pleura near to 
the surface, will sound " close under the ear" ; as 
the lungs move to and fro, it will be " double " ; 
being due to the roughening of the pleura, it 
will be heard only where the roughening exists, 



THE LUNGS. AUSCULTATION. 85 

and may therefore be very " limited in extent " ; 
and being produced by the movements of the 
lungs during respiration, it will " cease when the 
breath is held" 

Where the pleura is roughened immediately 
over the pericardium, the movements of the heart 
may be sufficient to produce the rubbing. This 
is called Pleuro-Pericardial Friction. When as 
sometimes happens, this is not modified by 
breathing, it will be difficult to distinguish from 
the friction sound, produced by a similar rough- 
ening of the pericardium (cf. pericardial friction), 

In inflammation of the pleura, so soon as the 
part becomes roughened, a friction sound is pro- 
duced. Soon the two layers are separated by 
an exudation of fluid, and the sound then dis- 
appears. When the inflammation subsides, and 
the fluid is reabsorbed, the two layers come once 
more into contact, and the friction sound is 
heard again. This is called Redux Friction, 
because it has come back. 

The same may occur with crepitation in some 
cases, and then it is spoken of in like manner as 
Redux Crepitation. 

When from some cause air gets into the 
pleural cavity, the case becomes one of Pneumo- 
thorax (air in the thorax). The lung then 
collapses away from the chest walls back to the 
spine round its roots, i.e. the bronchus and 



86 HOW TO EXAMINE THE CHEST. 

great vessels. As in the case of an effusion of 
fluid, the lung' is separated a long distance from 
the walls of the chest, though by air instead of 
fluid, and the voice and breathing sounds have 
to pass through a large air-containing chamber, 
before they reach the ribs. In most cases this 
has the same effect, as if the effusion were not 
air but fluid, and the vocal vibrations, the vocal 
resonance, and breathing sounds are either much 
diminished or absent. 

It might have been expected, that the air 
cavity would act like a sounding- box, and in- 
crease these sounds, and in some instances this 
does occur, but only when there is a large 
opening from the lung into the cavity, pro- 
viding free communication with the large 
bronchi. The sounds, which are produced in 
them, are then transmitted to the cavity, and 
become altered by consonance, so as to be more 
or less distinctly amphoric. Not only may the 
breathing and voice sounds become amphoric 
under these circumstances, but also crepitation. 
It has then received the name of Metallic Crepi- 
tation. 

Metallic Tinkling has a different explanation. 
It is caused by drops of fluid falling from the 
walls of a cavity into fluid below (gutta cadens), 
giving rise to the same sound as drops of water 
often do, when falling in a well or grotto. 



THE LUNGS. AUSCULTATION. 87 

When, over a pneumothorax, a coin is laid 
upon the chest walls, and tapped lightly with 
another, while the ear is placed upon the chest, 
the sound is often heard like the tapping of a 
metal bell or a porcelain dish. To this has been 
given the name of Bell Sound (bruit d'airain). 

It may be audible over any sufficiently large 
cavity. It is most common, though not constant, 
in pneumothorax, and in some of these cases 
ordinary percussion may be similarly metallic. 

When air has been for some time in the 
pleura, it is generally associated with an effusion 
of fluid, usually pus, but occasionally serum, and 
the names of Pyopneumothorax (air and pus in 
the pleura), and Hydropneumothorax (serous fluid 
and air in the pleura) are given respectively. 

This mixture of fluid and air in a large cavity 
gives rise to a new physical sign, which can only 
be met with under these conditions (air and 
fluid) } and which is therefore said to be " patho- 
gnomonic." This is Succussion, a splashing 
sound, heard when the patient is suddenly 
shaken, while the ear is resting upon the chest, 
though it may sometimes be heard at a distance 
from the patient. 

Succussion may also be produced in the 
stomach, a fact which must be borne in mind 
in diagnosing pneumothorax of the left side, 
though it can rarely cause any real difficulty. 



88 HOW TO EXAMINE THE CHEST. 

Theoretically all these sounds, amphoric and 
succussion, may be produced quite as well in a 
large cavity in the lung as in pneumothorax, 
although the cases are in practice rare, in which 
any confusion might arise. 

When, however, the opening into the lung is 
wide, the physical conditions are almost identical, 
and the diagnosis becomes very difficult from 
auscultatory signs alone. 



THE LUNGS. AUSCULTATION. 89 



SYNOPSIS. 

On auscultating tlie chest we must proceed 
systematically. We must listen : 

1. To the Voice Sounds, and determine whether 
they are symmetrical, i.e. whether they are equal 
on the two sides; if there be a difference we 
must note it, and ascertain whether it be an 
increase on one side, or a diminution on the 
other : 

2. To the Breathing Sounds, and ascertain if 
they be symmetrical or not ; we must listen, 
first, for the Inspiratory Sound, and next for the 
Expiratory Sound; if expiration be audible, we 
must note its length, duration, and intensity in 
comparison with inspiration, and may express 
the changes by the use of such terms as tubular, 
bronchial, &c. : 

3. We must listen for Superadded Sounds, such 
as are never audible in a healthy chest, for Crepi- 
tation, Friction, or sounds characteristic of large 
cavities, such as Amphoric or Cavernous Sounds, 
Metallic Echo and Tinkling, the Bell Sound, or 
Succussion, 



90 HOW TO EXAMINE THE CHEST. 



CONCLUSION. 

The detection of the early stages of disease of 
the lungs is often very difficult, and would be 
impossible without careful attention to minute 
details. 

The normal variations in the physical signs of 
the chest are so wide, and the transition between 
health and disease so gradual, that no sharp 
line of demarcation can be drawn between them. 
It is upon a want of symmetry in these physical 
signs that we chiefly rely. Most diseases of the 
lungs are unsymmetrical, either only one side is 
attacked, or if both sides are attacked, they are 
rarely affected to the same degree. So that the 
physical signs can hardly ever be symmetrical, 
and whether we inspect, palpate, percuss, or 
auscult, in all cases alike, it is for this want of 
symmetry that we are on the watch. 

In one place only (with the exception of the 
cardiac area) is there normally any want of sym- 
metry. This is at the right apex. There, for the 
reasons already mentioned, percussion is hardly so 
resonant, while the vocal vibrations, the vocal 
resonance and breathing sounds are slightly more 
intense, than on the left side. The difference is 



THE LUNGS. CONCLUSION. 91 

only slight, and the same difference against the 
left side instead of the right would be evidence of 
disease. 

Lastly, a diagnosis should never be based upon 
a single physical sign. An abnormality in one 
respect alone may be physiological. In disease 
of the lungs there will certainly be a concurrence 
of several physical signs, which separately might 
be worth little, but which taken together make 
the diagnosis certain. 

It is desirable, so far as possible, to represent 
all the facts observed in a diagrammatic form. 

Dulness may be represented by shading (or 
colouring) the corresponding parts of a diagram 
of the chest. Vertical lines maybe used to indi- 
cate that the dulness is due to solid lung, hori- 
zontal that it is due to fluid. 

Crepitation may be represented by dots or small 
circles according to the size (large, medium, or 
small). 

Cavities by irregular areas, described in the 
shaded parts. 

Pleuritic Friction by zig-zag lines. 

Other physical signs by initial letters. 
PI. = Flattening. 
Mts. = Movements. 
V. V. = Vocal vibrations. 
V. E. = Vocal resonance. 
Eh. = Ehonchus. 



92 HOW TO EXAMINE THE CHEST. 

Sb. = Sibilus. 
Pect. = Pectoriloquy. 
Mg. = iEgophony. 
I. = Inspiration. 
E. = Expiration. 
R. = Respiration. 
R. v". = Vesicular. - 
R. t. = Tubular. 

R. br. = Bronchial. )> Respiration. 
Rtr. = Tracheal. 
R. c. = Cavernous.- 
R + . = Prolonged respiration. 
R— . = Deficient respiration. 
I. = < > E. = Inspiration equal to, 
shorter, or longer than expiration. 



THE LUNGS. CONCLUSION. 93 



SYNOPSIS OF THE EXAMINATION OF THE LUNGS. 

In the accompanying table I have given tlie 
chief subdivisions of the examination of the lungs.; 
the details are given in the text, and are summa- 
rised at the end of each chapter. 

Inspection. 

The chest at rest. The shape. 
The chest in motion. The movements of respi- 
ration. 

Palpation. 

The vocal vibrations. 

The sense of resistance. 

Abnormal sensations (friction, &c). 

Percussion. 

The normal boundaries of the lungs. 
The resonance of the various parts of the 
chest. 

Auscultation. 

The vocal resonance. 
The breathing sounds. 
Superadded sounds. 



SECTION II. 



THE HEAET. 



THE EXAMINATION OF THE 
HEART. 



The examination of the heart is conducted upon 
the same system as that of the lungs. 
We consider : 

First — What we can see (Inspection). 

Secondly — What we can feel (Palpation). 

And lastly — What we can hear (Percussion 

and Auscultation), 



98 ' HOW TO EXAMINE THE CHEST. 



INSPECTION. 

That part of the thorax which is over the 
heart is called the Praecordium or the precordial 
region. 

On Inspection we consider 
First — its shape ; 
Secondly — the movements visible there. 



THE SHAPE. 

In health, there is nothing in the shape of the 
praecordium to indicate the position of the heart, 
and even in many forms of disease there is no 
perceptible change in it. 

Where, however, the heart is very large, espe- 
cially in young people, the praecordium may be 
unduly prominent, and it is then said to be 
Bulging. 

THE MOVEMENTS. 

When the heart is healthy, the only movement 
visible under ordinary circumstances is that of 



THE HEART. INSPECTION. 99 

the apex. This movement is seen in the fifth 
intercostal space, one inch inside, and usually 
about one inch and a half below, the left nipple. 
Measurements, however, taken with the nipple 
as a fixed point are unsatisfactory, because the 
nipple is not always found in exactly the same 
place. For this reason it is better to take instead 
of the nipple The Nipple Line. This is a line 
drawn from the middle point of the clavicle ver- 
tically downwards. It passes usually through 
the nipple. 

Position of the Apex. 

The Apex then is seen in the fifth intercostal 
space, one inch inside this line on the left side. 

In health, it is identical with the true ana- 
tomical apex of the heart, but, in disease, this is 
often not the case, and the impulse which we see 
frequently corresponds with a part of the left 
ventricle some distance from the anatomical 
apex. 

When we speak therefore "clinically" of the 
apex, we agree to mean that point on the left 
hand side of the chest furthest outwards and 
downwards, at which the movement of the heart 
can be seen or felt. This is often two or three 
inches from the normal place. 



100 HOW TO EXAMINE THE CHEST. 

Normal Peculiarities of the Apex. 

Tn children, the apex is often normally slightly 
higher and farther out than in adults, and may 
beat in the fourth interspace or under the 
nipple. 

In adults, when lying over on the left side the 
apex is often seen in the nipple line. Hence in 
fixing the apex, the patient must either stand 
erect, or, if lying down, must lie straight upon 
the back. 

The contraction of the abdominal muscles on 
standing up counteracts the tendency of the heart 
to fall, so that the apex is not displaced. The 
same occurs in the case of the liver, the upper 
border of which is if anything, a little higher 
when a person is standing up, than when he is 
lying down. 

Eespiration makes no perceptible difference in 
the position of the apex. 

Displacement of the Apex. 

When the apex is not in its normal place, it is 
said to be Displaced or dislocated. 

Even a very slight displacement may be of 
great importance, for there is hardly any disease 
of the heart or pericardium, in which the apex 
preserves its normal position. , 



THE HEART. INSPECTION. 101 

Thus, in disease of the mitral valve, and in all 
cases of enlargement of the right side of the heart, 
the apex is displaced outwards (i.e., to the left 
side) but it still remains in the fifth space. In 
disease of the aortic valves and in all cases of en- 
largement of the left ventricle, the apex is dis- 
placed not only outwards but also downwards, 
and is often found in the sixth or even the seventh 
space. 

In pericarditis, the apex is often raised, so as to 
beat in the fourth space. This is especially the 
case in children. 

Where the heart is displaced, the apex will of 
course be displaced also. 

This may happen in one or two ways, either by 
the heart being pushed out of its place, as, for 
instance, by the pressure of air or fluid in the 
pleural cavity, or by its being pulled out of its 
place, by the contraction of some part of the chest 
in relation with it. Which of these causes the 
dislocation is due to, must be determined by 
further examination. 

In some rare cases all the organs are placed 
upon the wrong side, e.g., the heart on the right 
and the liver on the left. This is spoken of as 
Transposition of Viscera. It is a very rare con- 
dition. 



102 HOW TO EXAMINE THE CHEST. 

The Character of the Apex Beat. 

In health, this is a simple slight bulging, due to 
the contraction of the ventricles, affecting a 
circle of about half an inch in diameter, such as 
we might expect to produce by tapping with one 
finger on the inside of the intercostal space. 

In disease, the apex beat is frequently altered 
in character. 

When it is visible over a much larg-er area 
than normal, it is described as Extended Cardiac 
Impulse. 

When it is not distinctly localised, it is spoken 
of as Diffused Impulse. 

When it is not a simple bulging, but has a 
wave-like movement, it is called Undulatory 
Impulse. 

When the intercostal space corresponding with 
the apex is drawn in, instead of bulging, each time 
the heart contracts, this alteration is described as 
Systolic Recession of the apex. 

Systolic recession is occasionally seen in the 
second, third or fourth spaces, but only when 
the patient is very thin, and is commonly asso- 
ciated with some contraction of the upper part 
of the left lung. 

Occasionally an impulse is seen at the apex, 
not only when the heart contracts, but also 
when it commences to dilate. This is called 



THE HEART. INSPECTION. 103 

" Diastolic Impulse " (or the back stroke of 
Hope). 



Pulsation in Abnormal Places. 

In disease, impulse synchronous with the move- 
ments of the heart is often seen at other parts of 
the chest beside the apex ; 

1. Below the xiphoid cartilage in the epigas- 
trium ; this is called Epigastric Pulsation :* 

2. In the second intercostal space, right and 
left of the sternum, in relation with the aorta on 
the right side, and with the pulmonary artery on 
the left ; this commonly occurs in cases in which 
the lungs are contracted at the apices : 

3. Occasionally on the right side in the fourth 
or fifth intercostal spaces, even as far as the right 
nipple ; this is due to displacement of the heart, 
but it is not the apex which beats here, for it is 
not a part of the left ventricle but of the right : 

4. Under the manubrium sterni; this is gener- 
ally due to disease of the great vessels (aneurysm) : 

5. In the vessels of the neck, either in the 
arteries (arterial pulsation) , or in the veins (venous 
pulsation) . 

* Pulsation is occasionally observed in the hepatic region, 
below the lower ribs on the right side. This usually is asso- 
ciated with heart disease, and is called Hepatic Pulsation. 



104 HOW TO EXAMINE THE CHEST. 

Arterial Pulsation is systolic, and due to the very 
forcible projection of blood into the vessels. 

Venous Pulsation is usually systolic, but may 
be also diastolic. 

When the beating of the heart is very forcible, 
the whole prsecordium is often lifted by it. This 
is known as General Heaving. 



THE HEART. INSPECTION. 105 



SYNOPSIS. 

On inspection then we look for 

1st. Changes in the Shape of the PrsBCordium. 

Bulging; 
2nd. Changes in the Movements, 

I. At the Apex, 

(a) Change in its position, 

(b) Change in its character, 

Increased, 
Extended, 
Diffuse, 
Undulatory, 
Diastolic impulse, 
Systolic recession; 

II. In other Places, 

General heaving, 
Epigastric pulsation, 
Pulsation over the aortic or pulmo- 
nary valves, 
Pulsation in other parts of thorax, 

(Aneurysmal) . 
Pulsation in sides of neck, 

(a) Venous. 

(b) Arterial. 

Pulsation in the hepatic region. 



106 HOW TO EXAMINE THE CHEST. 



PALPATION. 

As in the case of the examination of the lungs, 
speaking generally, all that can be seen can be 
also felt, both as regards the shape of the pra3- 
cordium and the movements of the heart. 

The movements are often more easily recog- 
nised by the hand than by the eye, and the 
position of the apex is always finally fixed by 
palpation. 

To Fix the Apex. 

This should be done with the tip of one finger, 
the object being to find out the exact point 
farthest outwards and downwards, at which the 
heart can be felt beating. 

Abnormal Sensations. 

Next the whole hand should be placed upon the 
prascordium, first below and then above, in order 
to detect either undue movement in this region, 
or abnormal sensations such as do not occur when 
the heart is healthy. 



THE HEART. PALPATION. 107 

The most peculiar of these abnormal sensations 
are described as Thrills. They are due to coarse 
vibrations, set up by eddy-like currents in the 
blood, in consequence usually of some obstruction 
to the course of its current. 

Thrills may be systolic or diastolic, i.e. may 
occur, when the ventricle is contracting or 
dilating. 

Of all thrills the most striking occurs at the 
apex, and has been aptly compared to the sensa- 
tion felt when the hand is placed upon the back 
of a cat purring, and from this it has received the 
name of Purring Tremor, or Fremissement Cataire. 
It occurs immediately before the contraction of 
the ventricle, and is therefore called presystolic. 

Similar thrills are occasionally felt in the second 
or third intercostal spaces on the right or left side. 
They are most common on the right side, and are 
connected with affections of the aortic valves. 
Occasionally the vibrations occur at such regular 
intervals as to produce a musical note. To this 
reference will be made again under auscultation. 

When the two layers of the pericardium are 
roughened, the rubbing of the two surfaces 
together may be easily heard, but it is some- 
times also felt. It is called Pericardial Friction 
or Friction Rub. 

Thrills, as well as also friction, are sometimes 
felt under the manubrium sterni. In these cases 



108 HOW TO EXAMINE THE CHEST. 

they are due usually to aneurism of the arch of 
the aorta. 

In the neck, thrills are occasionally felt both in 
the arteries and veins. In the arteries, they are 
usually propagated from some point below, 
generally from the aortic valves. In the veins, 
they are commonest in cases of extreme anaemia, 
e.g. chlorosis. 

When the valves of the pulmonary artery close 
forcibly in thin people, their closure may be fre- 
quently felt by the hand as a sharp flap or shock 
in the second left intercostal space. This is 
often visible, as well as to be felt, and has 
already been referred to under Inspection. It 
has received the name of Valve Shock (Klap- 
penstosz). 



SYNOPSIS. 

Palpation enables us to confirm most of the 
facts recognised on inspection, and further to 
ascertain the occurrence 

1. Of Thrills, 

(a) Systolic, 

(b) Diastolic, 

(c) Presystolic; 

2. Of Valve Shock ; 

3. Of Friction. 



THE HEART. PERCUSSION. 109 



PEKCUSSION. 

The Size of the Heart. 

How Large is the Heart ? As with the lungs, 
so with the heart, this is naturally the first 
important question, and it can only be answered 
by means of percussion. 

It has been already stated, that part of the 
heart is uncovered by the left lung, and that this 
part lies just above the diaphragm to the left of 
the middle line of the sternum (Jig. 20). If we 
percuss this part we obtain a non-resonant sound, 
for the reason that there is no air-containing 
lung beneath. 

The Cardiac Area is, roughly speaking, a tri- 
angular space. To describe a triangle three 
points are required, and these three points are : 

1. The apex, which is to be found in the fifth 
intercostal space one inch inside the left nipple 
line; 

2. The junction of the fourth left costal car- 
tilage with the sternum ; 

3. The bottom of the sternum at its junction 
with the xiphoid cartilage. 



110 HOW TO EXAMINE THE CHEST. 



FlG. 20. 




Diagram showing the real size of the heart, and the size of 
the absolute cardiac dulness. 

1, 2, 3, are the three points described in the text. 



THE HEART. PERCUSSION. Ill 

The area of cardiac dulness may be then 
described by drawing 

1. One line (the Upper Boundary) slightly 
curved outwards from the apex to the junction 
of the fourth costal cartilage with the sternum 
on the left side; 

2. A second (the Lower Boundary) from the 
apex to the base of the xiphoid cartilage ; this 
is nearly horizontal ; 

3. A third (the Right Boundary) from the base 
of the xiphoid cartilage vertically upwards along 
the left border of the sternum to the fourth 
costal cartilage. 

Within this area the percussion sound will be 
dull, or, if not absolutely dull, will be much im- 
paired. This area is called the area of Absolute 
— or Superficial — Cardiac Dulness. It does not, 
of course, represent the real size of the heart, 
which we know occupies a much larger space in 
the thorax (fig. 20). If we percuss forcibly 
outside the upper boundary, we obtain a note, 
which, though more resonant than within the 
area described, is still less resonant than the note 
in other parts of the chest, for by forcible per- 
cussion we throw into vibration the deeper parts 
of the chest, and these are, of course, less 
resonant where the heart is, than where there is 
nothing but lung tissue. This increased area of 
impaired resonance is called the Deep — or Rela- 



112 HOW TO EXAMINE TEE CHEST. 

tive — Cardiac Dulness. It extends about three 
quarters of an inch beyond the upper border of 
the area of absolute dulness along the fourth 
rib, and curves down to fuse with it at the apex 

(fig- 20). 

The Lower Boundary cannot be determined by- 
percussion, for the heart lies here upon the 
diaphragm, and the diaphragm upon the liver, 
and both the heart and the liver give a dull note 
to percussion. This boundary may be, however, 
accurately represented by drawing a horizontal 
line from the apex of the heart to the base of 
the xiphoid cartilage. This line is in direct 
continuation with the upper border of the area 
of hepatic dulness described previously. 

The right border of the heart cannot be shown 
by percussion to extend beyond the left edge of 
the sternum, and for this reason. The sternum 
is a solid body, lying above and to the right side 
immediately upon the lungs. When it is per- 
cussed we obtain vibrations, not only from the 
parts immediately beneath, but also by conduc- 
tion from the lungs in relation with it at a 
distance from the part percussed, and the sound 
is then resonant, even on parts of the sternum 
under which no lung lies. 

When from any cause, as for instance by 
enlargement of the right side of the heart, the 
lung is pushed away from the sternum, the 



THE HEART. PERCUSSION. 113 

resonance over it will become impaired, or even 
absolutely dull. 

If the lungs and the pleura are normal, any 
increase in the size of the heart is attended by a 
correlative increase in the size of the cardiac 
dulness, but, if the lungs and pleura be not 
healthy, a difficulty may arise in one of three 
ways. 

1. If the lungs be too large, as in emphysema, 
they will encroach upon the cardiac area, and 
cover up the heart, either wholly or in part, and 
the cardiac dulness will then be either wholly 
absent, or be much reduced in size {fig 12). 

2. If the lungs be contracted, as they often are 
in chronic affections, more of the heart will be 
exposed, and the cardiac dulness will be propor- 
tionately increased {fig. 13). 

3. Lastly, if the lungs be consolidated, or the 
pleura be diseased, in those parts which are in 
immediate relation with the heart, we shall obtain 
on percussion a dull note, as over the heart itself, 
and our means of determining the heart's dulness 
will be lost. 

Alterations in the Cardiac Dulness. 

Diseases of the heart, in almost every case 
except atrophy, — and this cannot be clinically 
demonstrated — are attended by increase in its 

8 



114 HO.W TO EXAMINE THE CHEST. 



Fig. 21. 




Diagram showing the shape of the absolute cardiac dulness in 
aortic disease (enlargement of the left ventricle). 

Apex displaced downwards and outwards. The white dotted 
line shows the normal area of absolute cardiac dulness. 



THE HEART. 



PERCUSSION. 



m 




Diagram showing the shape of the absolute cardiac dulness 
in mitral disease (enlargement of the left auricle and of the 
right side of the heart). 

Apex displaced outwards and not downwards. Great in- 
crease of dulness to the right. 

The white dotted line show3 the normal area of absolute 
cardiac dulness. 



116 HOW TO EXAMINE THE CHEST. 



Fig. 23. 




Diagram showing the shape of the absolute cardiac dulness 
in a case of large pericardial effusion. 

The white dotted line indicates the normal area of absolute 
cardiac dulness. 



THE HEART. PERCUSSION. 117 

size, and therefore by increase in the size of the 
cardiac dulness. This is easily determined unless 
the lungs and pleura be also affected. 

When the cardiac dulness is increased, its shape 
varies much, according to the kind of disease with 
which the heart is affected. 

The shape may remain triangular and be simply 
enlarged. This is the rule in all cases of hyper- 
trophy of the left ventricle, of which aortic disease 
may be taken as the type {fig. 21). 

Or, it may cease to be triangular, and become 
either irregularly quadrilateral, as in mitral 
disease {fig. 22), or roughly globular, as in cases 
of great general enlargement or of pericarditis 
{fig. 23). 

Lastly, the cardiac dulness will be displaced 
when the heart is displaced, or be altered in size 
and shape in consequence of deformities in the 
thorax. 



SYNOPSIS. 

By percussion, then, 

1. We determine the size of the cardiac 
dulness, 
And 2. Ascertain any alterations in its size, shape, 
or position. 



118 HOW TO EXAMINE THE CHEST. 



AUSCULTATION. 

"When the ear is placed upon the cardiac 
region of a healthy man, the two sounds of the 
heart become audible. They differ somewhat in 
character, and have been compared to the two 
syllables " lab " and " dup," the first being longer 
and heavier (lab), the second shorter and sharper 
(dup). 

The heart, we know, is in constant movement, 
either contracting or dilating, and this is true of 
the auricles as well as the ventricles, but, inas- 
much as it is the contraction of the ventricles 
which is the most important, we agree, when the 
terms contraction and dilatation are used, to refer 
to what the ventricles are doing, unless we dis- 
tinctly specify some other part. 

The ventricle then is continually moving, never 
absolutely at rest, but always either contracting 
or dilating. Directly contraction ends, dilatation 
begins, and vice versa. 

We may represent the heart's action diagram- 
matically in the form of a circle (fig. 24), once 
round the circle representing one complete cycle 
of the heart's action. 



THE HEAET. AUSCULTATION. 119 

The movements of the heart are associated with 
the two sounds already referred to. These may- 
be represented upon the diagram by shaded 
spaces cutting the circle, the first much thicker 
than the second, to indicate its greater length. 

Fig. 24. 




Diagrammatic representation of the heart's action. 

S = the systolic period. 

D = the diastolic period. 

I = the first sound of the heart. 
11 = the second sound of the heart. 
111 = the presystolic, or auricular systolic, period. 

We have, then, in investigating the heart's 
action to consider, first the two sounds of the 
heart, and secondly the two intervals by which 
these sounds are separated. These intervals in 
health are periods of silence. 

It will be observed in the diagram, that the 
shaded spaces divide the circle into unequal 
parts, the shorter bearing to the longer roughly 
the relation of two to three, that is to say, the 
shorter is two-fifths of the whole circle, and the 



120 HOW TO EXAMINE THE CHEST. 

longer three-fifths. This is approximately the 
relation, which has been found by measurement to 
exist, between the length of the period of contrac- 
tion and of the period of dilatation. 

To the shorter of these periods, the period of 
contraction, the name Systole is given, and to the 
longer, the period of dilatation, the name Diastole. 
Systole and diastole are therefore periods of time, 
and, though they stand in a certain relation to the 
sounds of the heart, are to be carefully distin- 
quished from them. We have therefore, when 
listening to the heart, to observe, first the two 
heart sounds, and secondly the two periods of 
silence. 



The Sounds of the Heart. 

The chief cause of the second sound of the 
heart is the closure of the semilunar valves in the 
aorta and in the pulmonary artery. 

The first sound is more complex, and although 
it is due in part to the closure of the auriculo- 
ventricular valves, other factors appear to be 
necessary for its normal production, such as a 
healthy condition of the muscular tissue of the 
heart and of the blood. 

As the result of observation of the heart sounds 
in disease, it is probable that, even for the second 



THE HEART. AUSCULTATION. 121 

sound, the simple theory of its production by the 
closing of valves does not by itself afford a suffi- 
cient explanation in all cases. 

The valves, however, play so much the most 
important part in the production of the pounds 
of the heart, that it will not be necessary in this 
place, to consider the other possible causes, but 
we may assume for our present purpose, that the 
heart sounds are due in all cases alike to the closure 
of valves. 

The first sound is long, rather dragging, and 
well represented by the syllable "lab." This is 
indicated upon the diagram by a broad shaded 
space. The second sound is flapping in character, 
shorter, and sharper, and is well represented by 
the syllable " dup." It is indicated upon the 
diagram by a narrow shaded space. 

We have no means at present of measuring the 
length of the heart sounds. The figure given 
is diagrammatic, and indicates their duration only 
approximately. 

The first sound of the heart is produced, when 
the ventricle begins to contract, and marks there- 
fore the commencement of the period of systole. 
The second sound is produced, when the ventricle 
begins to dilate, and marks therefore the com- 
mencement of the period of diastole. Systole 
therefore extends from the first sound up to the 
second; diastole from the second up to the first. 



122 HOW TO EXAMINE THE CHEST. 

The first sound is sometimes spoken of as the 
systolic sound, and the second as the diastolic 
sound. These terms are confusing and should 
not be used. 

The characters of the sounds in health are suffi- 
ciently distinct, so that there is little risk of 
mistaking them, but this is not so in disease, and 
it becomes necessary to have some means of 
determining, which sound it is that we hear, or 
if, as occurs in many cases, the sounds be absent, 
to determine when the heart is contracting, and 
when it is dilating, i.e., "To time the Heart." 

This is easily done by means of the pulse. 
The pulse beat is due to the sudden driving of 
blood into the vessels by the contraction of the 
left ventricle. Near the heart the pulse beat 
and the systole of the ventricle are practi- 
cally synchronous, but at a distance from the 
heart this is not so, for the wave is delayed in 
reaching a distant vessel, as for instance the 
radial at the wrist, and in disease this retarda- 
tion is often considerable. Some vessel must 
therefore be selected as near as possible to the 
heart. The most suitable for the purpose is the 
carotid. 

This will be conveniently reached by grasping 
the side of the neck with one hand, the fingers 
being behind, and by pressing the thumb down in 
front between the sterno-mastoid muscle and the 



THE HEART. AUSCULTATION. 123 

larynx or trachea. The carotid will then be felt 
pulsating beneath the thumb. 

The pulse wave in the carotid is a long one, 
and lasts as long as the period of contraction. 

Asystolism. 

The heart is a complex organ formed of many- 
parts. It might be supposed, then, that we should 
get many sounds instead of only two, and yet in 
health the two sides of the heart act in such per- 
fect harmony together, that they produce only one 
first sound and only one second sound. This is by 
no means so in disease, for, when this accurate 
adjustment is disturbed, the two sides cease to 
act synchronously together, and the sounds 
become double, or as they are called Reduplicated. 
Instead of a clear "lab-dup, lab-dup," we hear 
as it were " lar-rab-dur-rup, lar-rab-dur-rup." 
This has also been called Cantering (Bruit de 
Galop) . 

Either sound may be reduplicated, though it is 
more commonly the second. 

The condition of the heart, under which this 
reduplication is observed, has received the name 
of Asystolism. This term means merely, that the 
two sides do not act together at exactly the same 
time (= asynchronism) . Sometimes, where the 
want of harmony is not so marked as this, the 



124 HOW TO EXAMINE THE CHEST. 

relative loudness of the sounds on the two sides 
of the heart may be altered. These louder sounds 
are called Accentuated. 



Murmurs. 

We have stated, that in a healthy heart we hear 
two sounds only, and that they are separated by 
two periods of silence. In disease we often hear 
during these periods of silence a fresh sound, and 
this we agree to call a murmur. 

A Murmur may be defined to be a sound, pro- 
duced by the movements of the heart, occurring 
in those intervals, during which in health no sound 
is audible. 

Murmurs must not be confounded with heart 
sounds, nor must they be spoken of as simply 
replacing the heart sounds. They may, it is true 
replace the heart sounds, but then they always 
do something more, and the two things are essen- 
tially distinct. 

Murmurs may be heard, when both the sounds 
are present, or when one of the sounds is absent, 
or even both of them, and lastly, the heart sounds 
may be modified, or even absent, without any 
murmur at all. 

The terms, employed to describe the characters 
of murmurs, are those in ordinary use, such 



THE HEAET. AUSCULTATION. 125 

as soft, hlowing, loud, faint, harsh, grating, 
rasping, &c. 

Some are musical in character, and are then 
spoken of as musical murmurs. Commonly- 
deep in tone, but occasionally high pitched, 
such murmurs will be described as cooing, 
piping, whistling, &c, according to the kind of 
musical sound produced. They frequently change 
their tone and character, and occasionally the 
musical part may even for a time disappear. 
These variations depend upon varying conditions 
of the circulation. 

The vibrations, which produce these musical 
murmurs, are often also easily felt, and give rise 
to some of the more striking forms of thrills. 
Heart murmurs, even when distinctly musical, are 
not often heard by the patient, however loud they 
may appear to the person auscultating. 

Classification of Murmurs. 

Cardiac murmurs are divided into two groups, 
according as they are produced inside, or outside 
the heart, and they are named accordingly Endo- 
cardial and Exo-cardial. 

The exocardial murmurs will be discussed 
later. Of the endocardial murmurs there are two 
classes, 

I. Those which depend upon some pathological 



126 HOW TO EXAMINE THE CHEST. 

change in the heart, and which are therefore 
called Organic ; 

II. Those, in which no such change exists, 
and which are therefore called Inorganic. 

Murmurs may also be classified according to 
the movements of the heart. 

The heart is always either contracting or dila- 
ting, and murmurs, therefore, fall naturally into 
two groups, 

I. Those which occur during the period of 
contraction (systole); these are called Systolic 
murmurs ; 

II. Those which occur during the period of 
dilatation (diastole) ; these are called Diastolic 
murmurs. 

How to Time Murmurs. 

We are able, as we have seen, to determine, 
by feeling the pulse, the time at which the left 
ventricle contracts. 

If, then, we place our ear upon the chest and 
our finger upon the carotid, and hear a murmur, 
we know, should the murmnr come at the same 
time as the pulse beat, that it occurs when the 
ventricle is contracting, and that it, therefore, is 
a systolic murmur. On the other hand, should 
the murmur not come at the same time as the 
pulse beat, we know that it is produced when the 



THE HEAET. AUSCULTATION. 127 

ventricle is not contracting, but dilating, i.e. 
during diastole, and that the murmur is therefore 
diastolic. 

We may indicate the murmurs which we hear 
upon the diagrams, by shading lightly (or in a 
different colour) the spaces left between the 
darker shadings, which represent the heart 
sounds, varying the depth of shading with the 
intensity of the murmur. Thus fig. 25, repre- 

FiG. 25. 




Diagram of a systolic murmur with both heart sounds 
audible. 

The gradually decreasing intensity of the murmur is indi- 
cated by lighter shading. 

sents a systolic murmur. The shading runs 
directly into that corresponding with the first 
sound. This indicates, that the murmur in this 
case was continuous with the first sound, and could 
not be separated from it. The shading is darkest 
towards the first sound, and becomes lighter 
towards the end of systole. This indicates, that 
the murmur was loudest at the commencement, 



128 HOW TO EXAMINE THE CHEST. 

and that it gradually became fainter towards the 
end, of systole. 

In a similar way most varieties of murmurs 
may be diagrammatically represented. 

Subdivision of Endocardial Murmurs. 

Systole is a much shorter period of time than 
diastole, and we do not find it possible to sub- 
divide the class of Systolic Murmurs. We con- 
tent ourselves with speaking of them as and Long 
Short. 

Diastole is a longer period and, moreover, when 
change occurs in the rate of beating of the heart, 
it is at the expense of the diastole that this 
chiefly takes place. 

Diastolic Murmurs are easily subdivided into 
two groups, according as they occur at the 
commencement, or at the end, of the diastolic 
period. 

The murmur at the end of Diastole gradually 
increases in intensity up to the first sound, and is 
terminated abruptly by it ; it comes immediately 
before the systole, or, if we have one finger upon 
the carotid, immediately before the pulse beat 
there. It is called, therefore, a Presystolic mur- 
mur (before the systole) (fig. 26). It is usually 
associated with the peculiar purring thrill pre- 
viously described. 



THE HEART. AUSCULTATION. 129 

Now, what is happening in the heart at the 
time at which this murmur is produced ? 

We know that immediately before the ven- 
tricle contracts, the auricle contracts, so as to 
ensure the complete filling of the ventricle with 
blood. But this is just the time at which the 
murmur is heard. It has for this reason received 

Fig. 26. 




Diagram of a pra3systolic murmur (auricular systolic). The 
first sound is longer than normal, and the second sound is 
absent. 

The murmur increases in intensity up to the first sound, and 
is abruptly terminated by it. 

the name of Auricular Systolic, by which is meant, 
that it is due to the contraction of the auricle. 
It is better, however, to use the more common 
term, and call it Presystolic. 

The other kinds of diastolic murmur are heard 
at the commencement of Diastole. They are 
spoken of as Long or Short. 

The very short murmur of this kind, which 
occurs immediately after the pulse beat, or if the 
second sound be present, immediately after the 

9 



130 



HOW TO EXAMINE THE CHEST. 



second sound, has received the name of Postsystolic 

(after the systole). It is, however, of but little 
importance (fig. 27). 

Fig. 27. 




Diagram of a short postsystolic murmur, immediately fol- 
lowing and continuous with the second sound, which is still 
audible. 

Fig. 28. 




Diagram of an ordinary diastolic murmur (long post- 
systolic). 

The second sound is lost in the murmur. 

The most common kind is usually described as 
Diastolic, or, in order to distinguish it from the 
presystolic murmur, Ordinary Diastolic. This, 
however, often leads to confusion and seems to 
imply, that a presystolic murmur is not diastolic, 
as it clearly is. 



THE HEART. AUSCULTATION. 131 

It would be better, I think, to speak of all those 
murmurs, which occur at the commencement of 
diastole as Postsystolic, and subdivide them into 

Fig. 29. 




Diagram of a double murmur, systolic and long post- 
systolic. 

Both sounds are lost in the murmurs. 



Pig. 30. 




Diagram of a double murmur, presystolic and systolic. 
The first sound is audible and the second absent. 

Long and Short, the long answering to what 
is usually called the ordinary diastolic, the 
short to what is more commonly called the 
post systolic. 



132 HOW TO EXAMINE THE CHEST. 

The murmurs might then be tabulated thus : 



Jr Long. 
S y stoUc {short. 



Murmurs < 

D' tT I Presystolic == Auricular systolic. 

*- i Postsystolic, long = ordinary Diastolic. 

short = ordinary Postsystolic. 



The Cause of Endocardial Murmurs. 

Murmurs in the heart (or vessels) are due to 
eddies set up in the blood. These will be pro- 
duced, whenever a current of fluid has to pass 
through a narrow aperture into a larger space, 
the eddies thus set up generating a sound. 

It might be supposed, with such an explanation, 
that murmurs would be constantly produced, 
even in a healthy heart, inasmuch as the blood 
has to pass through the narrow valvular orifices 
into the larger cavities of the ventricles or vessels, 
but, as long as the normal relation exists between 
the size of the orifices and that of the cavities or 
vessels, w r e know that murmurs are not heard ; 
so soon, however, as this normal relation is dis- 
turbed, murmurs are likely to arise. 

Theoretically they may depend upon changes of 
two kinds : first, dilatation of the cavities into 
which the blood is passing, the orifices being 
unaltered ; or, secondly, alteration in the condition 
of these orifices, the cavities remaining normal. 
These conditions are usually associated. We meet 



THE HEAKT. AUSCULTATION. 



188 



with both kinds of murmurs clinically, but inas- 
much as it is most common to find, when endo- 
cardial murmurs have been heard, that the 
orifices are altered, we will for the present 
confine our attention to those murmurs which are 
due to valvular lesions, and consider the means 
we have of determining at which orifice of the 
heart the disease exists. 



ENDOCARDIAL MURMURS DUE TO VALVULAR 
DISEASE. 

The Place of Murmurs. 

Murmurs are transmitted in the direction in 
which the blood is passing at the time of their 
production. Let us take an instance. If a 
murmur is produced at the aortic orifice at the 
time when the blood is being driven through it 
by the contraction of the ventricle, the murmur 
will be carried along the aorta upwards, and will 
be heard some distance above the valves. In the 
same way, if the murmur is produced when the 
heart is dilating, the valves being incompetent, 
and allowing a stream of blood to pass back 
through them into the ventricle, the murmurs 
will be heard below the valves, that is to say, on 
the ventricular side of them. Murmurs have, 



134 HOW TO EXAMINE THE CHEST. 



Fig. 31. 




Diagram of the heart, showing the anatomical position of the 
valves, the axes of the aorta and pulmonary artery, and the 
places where to put the stethoscope, when examining the dif- 
ferent orifices of the heart. 

The dark lines A, P, M, tr indicate the actual position of the 
aortic, pulmonary, mitral, and tricuspid valves respectively. 

The thin lines the axes of the aortic and pulmonary orifices. 

The circles A, P, M, tr the places upon which to put the 
stethoscope, when examining the corresponding orifices. 



THE HEART. AUSCULTATION. 135 

therefore, been spoken of as Onward and Back- 
ward murmurs, that is, murmurs which are pro- 
pagated onwards, in the direction of the normal 
current, or backwards, contrary to the normal 
current. This fact is of the greatest importance, 
because it gives us the means of fixing with 
certainty the place at which a given murmur is 
produced. 

We require to know first the normal position of 
the valves of the heart. 



The Position of the Valves. 

Anatomically they lie very close together, as 
is shown in the diagram {fig. 31), so that if the 
mouth of a stethoscope were placed at the junc- 
tion of the third left costal cartilage with the 
sternum at its upper border, it would cover the 
middle points of three out of the four valves, the 
one not covered being the tricuspid. 

At this point, then, it would be impossible to 
separate the murmurs with certainty, for the pul- 
monary valve lies immediately above the aortic, 
and the mitral behind and a little to the left of 
them both. 

If the left hand be loosely clenched, and placed 
upon the chest, so that the knuckles of the middle 
phalanges of the fingers rest upon the sternum, 



136 HOW TO EXAMINE THE CHEST. 




Diagram of the left hand placed upon the chest to represent 
the size of the heart and the position of its various parts. 

Dotted lines indicate the size of the heart {fig. 20) and of 
the absolute cardiac dulness. 

For description see text. 



» THE HEAET. AUSCULTATION. 137 

we shall obtain a rough estimate of the size of 
the heart aud of the relative position of its dif- 
ferent parts in that individual, as the diagram 
shows (fig. 32). 

The row of knuckles represents the line of the 
tricuspid valve, and what is seen of the fingers 
towards the right the right auricle. A line, 
drawn from the knuckle of the first finger to the 
carpal end of the ulnar, divides the back of the 
hand into two unequal parts ; the larger and lower 
represents the anterior surface of the right ven- 
tricle, the upper and smaller that of the left ven- 
tricle, while the line itself corresponds with 
the septum. The knuckle of the thumb marks 
the position of the left auricle. If the thumb be 
now straightened, it will indicate the direction 
which the aorta takes in the first part of its 
course ; and if a pencil be grasped by the hand, 
as in the diagram, it will cross the thumb, and lie 
in a similar position, directed towards the opposite 
side, and will represent the direction which 
the pulmonary artery takes in the first part of 
its course. 



The Axes of the Heart. 

We may draw a line in the direction of the 
thumb and of the pencil, and these we may 



138 HOW TO EXAMINE THE CHEST. 

speak of as the Axes or lines of direction of the 
aorta and of the pulmonary artery respectively. 

Now, it is along these axes, onwards or back- 
wards, as the case may be, that murmurs pro- 
duced at these orifices will be propagated. 

By observing, then, in which direction a mur- 
mur travels, we are enabled to say with accuracy 
at which orifice the murmur is produced. 

We may define the Axis of the Aorta to be a 
line drawn from the apex of the heart to the right 
sterno-clavicular articulation, and the Axis of the 
Pulmonary Artery to be a line drawn from the 
middle of the xiphoid cartilage to the left sterno- 
clavicular articulation {fig. 31). 

These lines, it will be observed, cross the end 
of the second costal cartilage close to the sternum, 
and if we place the stethoscope upon them in the 
second intercostal space, right or left of the 
sternum, we have placed it upon points respec- 
tively nearest to one of the valves, and at the 
same time farthest from the other. We say, 
therefore, that in order to examine the condition 
of the aortic valves, we place the stethoscope, in 
the position indicated (a) in the diagram, in the 
second right intercostal space, and of the 
pulmonary valves (p) in the second left inter- 
costal space. 

We will now consider more particularly the 
aortic murmurs. 



THE HEART. AUSCULTATION. 139 

Systolic aortic murmurs, that is to say, mur- 
murs which are produced at the aortic orifice, 
when the blood is being driven out of the left 
ventricle, will travel in the axis of the aorta 
upwards towards the right sterno-clavicular joint, 
and will be heard above the valves here or even 
further in the course of the large arteries. Dia- 
stolic aortic murmurs, on the other hand, which 
are produced by the blood passing back again 
into the ventricle, will be propagated in exactly 
the opposite direction, that is to say, towards 
the apex of the heart. They are often trans- 
mitted with great intensity along the whole 
length of the sternum, even as far as the xiphoid 
cartilage. 

Where these murmurs are very faint, they are 
often not intense enough to reach the apex, and 
may then be heard at a point in the axis of the 
aorta short of the apex, the commonest place being 
on the level of the fourth left costal cartilage. 
Sometimes it is only in this place that these 
murmurs are audible. 

What has been said of the aorta is true, 
mutatis mutandis, also of the pulmonary artery. 

In the case of the mitral valve the difficulties 
are greater. The line of direction or Axis of the 
Mitral orifice may be roughly taken to be a line 
drawn from the apex of the heart to the left 
interscapular space posteriorly, on a level with 



14.0 HOW TO EXAMINE THE CHEST. 

the sixth dorsal vertebra. If a long skewer 
were taken, and thrust into the chest at the apex 
of the heart, and brought out at the point men- 
tioned behind, it would represent the axis of 
the mitral orifice, and give therefore the line of 
direction, which the blood follows in passing* 
from the left auricle into the left ventricle. 

If, then, a murmur is produced at the orifice 
when the ventricle is contracting, it would be 
caused by a stream of blood passing backwards 
from the left ventricle into the left auricle in a 
direction contrary to the normal current of 
blood. We should expect, therefore, to hear 
such murmurs posteriorly in the left inter- 
scapular space. 

If, however, the murmur is produced when the 
ventricle is dilating, it would be caused by a 
stream of blood passing in the opposite direc- 
tion, that is, in the same direction as the normal 
blood current, and we should expect not to hear 
it behind. 

Now this is just what occurs. Both kinds of 
murmurs, then, are audible at the apex, but the 
systolic only behind. 

The mitral valve, however, lies so deep down, 
that the nearest points along the axis, which we 
can reach, to the valve itself are the apex of the 
heart in front, where the left ventricle becomes 
superficial, and the left interscapular space 



THE HEART. AUSCULTATION. 141 

behind ; and these are the spots we choose to 
listen at, when we wish to examine the condition 
of the mitral valve. The fourth valve, the 
Tricuspid, lies superficial. Murmurs produced 
at this orifice we hear best immediately over the 
valve, that is, along the lower part of the 
sternum. 

The places, then, at which we listen for 
murmurs at the different orifices are 

1. At the aortic, in the second right inter- 
costal space close to the sternum; 

2. At the pulmonary, in the second left inter- 
costal space close to the sternum ; 

3. At the mitral, at the apex of the heart ; 

4. At the tricuspid, at the bottom of the 
sternum. 

But it is not sufficient to note the presence 
only of a murmur at these places. We must 
also carefully trace the direction in which it is 
propagated, and determine especially the spot 
at which it is heard loudest, i.e. its place of 
maximum intensity. 



The Diagnosis of Valvular Diseases. 

Now, at each of these places we have to 
consider, as has already been stated, first, the 
two sounds of the heart, and, secondly, any 



142 HOW TO EXAMINE THE CHEST. 

murmurs wliicli are heard between them, and we 
may therefore construct for each of these spaces 
a diagram similar to that already described. 

The heart being thus a complex organ, all the 
various parts of which stand in such close rela- 
tion in action to each other, we should expect to 
find, that it would be almost impossible to meet 
with any change in one part, which was not 
associated with correlative changes in other 
parts. Hence the rule to examine each and 
every part of the heart, and to note carefully 
every one of the changes there detected, before 
venturing to make a diagnosis of any disease. 

We have therefore four places to listen at, 
and at each of these places we have two sounds 
and two intervals to consider. 

The sounds may be both present, or one or 
both absent. They may be accentuated or 
reduplicated. 

If murmurs be present, we have then to deter- 
mine to which of the intervals they belong, i.e. 
whether they be systolic or diastolic; and if 
diastolic in which part of the diastole they 
occur. 

Examination of the heart, then, is a com- 
plicated undertaking, and must be conducted 
systematically, if a correct diagnosis is to be 
made. 

It is well to represent, so far as possible, all 



THE HEART. AUSCULTATION. 



143 



the information we can obtain in a diagrammatic 
form. 

Fm. 33. 




B. 
C. 



Complete diagram of a case of mitral stenosis. The black 
area shows the size and shape of the absolute cardiac dulness. 
A. Valve shock. 

Epigastric pulsation. 
Venous pulsation. Veins dilated. 
Dotted circle indicates the area within which the 
murmur is heard and a presystolic thrill felt. 
X. Shows the point of maximum intensity. 

For the purpose of illustration a simple and 
well-marked case of mitral stenosis has been 



144 



HOW TO EXAMINE THE CHEST. 



selected, that disease which, gives rise to the pre- 
systolic murmur already frequently referred. to. 



Fig. 34 





A is the representation of what is heard in the second right, 
p in the second left intercostal space, and M at the apex. 

The pulmonary sounds are louder than the aortic. This is 
indicated by darker shading, and the second sound is redupli- 
cated. 

At the apex the first sound is prolonged and loud, the second 
sound is absent, and there is a long presystolic murmur. 

Such diagrams are much easier to read than 
long verbal descriptions, and the construction of 
them tends to clearness of conception. 



THE HEART. AUSCULTATION. 145 



ENDOCARDIAL MURMURS NOT DUE TO VALVULAR 
DISEASE. 

We are now in a position to consider some of 
the other kinds of murmurs audible in the car- 
diac region. 

The remaining organic endocardial murmurs 
are due for the most part to roughenings or little 
outgrowths (vegetations) from some part of the 
inner walls of the heart, and occasionally to local 
pouchings (aneurysms) of the heart walls. 

These conditions are all of them rare, and are 
sometimes impossible to diagnose. The points 
upon which chief stress would be laid, are the 
evidences of some organic heart disease, but 
without the physical signs which indicate any of 
the ordinary forms of valvular lesion. 



10 



146 HOW TO EXAMINE. THE CHEST. 



INORGANIC MURMURS. 

The Inorganic Murmurs, i.e. those not asso- 
ciated with, gross pathological change in the 
heart, form a large and important class. 

They are rarely loud, harsh, murmurs, but for 
the most part soft and blowing, and are nearly 
always systolic. 

They may be heard in almost any part of the 
cardiac area, but they are not propagated, as a 
rule, along the various axes, as organic murmurs 
are, and they vary much in different individuals, 
and even in the same individual at different 
times. 

Their varying character, and their usual disap- 
pearance in the course of time, are points of diag- 
nostic importance, but they are frequently very 
difficult to distinguish from some of the murmurs 
due to organic lesions. 

The commonest form of inorganic murmur is 
heard in the second left intercostal space near the 
sternum and a little below this place. It is called 
a Pulmonary Systolic murmur, and is referred 
usually to the eddying of the blood, as it passes 
the pulmonary orifice. 

A similar systolic murmur is often heard lower 
down in the third space just within the left 



THE HEART. AUSCULTATION. 147 

nipple line. This is possibly produced in the left 
auricle. 

Or again, between the left nipple and the apex 
of the heart, and this is probably produced in the 
left ventricle. 

The loudest and also the rarest inorganic mur- 
mur is heard over the right ventricle in the region 
of the Tricuspid valve. 

All these murmurs, as has been already stated, 
are systolic. So far as we know at present, dias- 
tolic inorganic murmurs do not occur in the car- 
diac region. 

The causes of these murmurs- are not yet quite 
established. 

From the fact that they are very commonly 
found in conditions of great anaemia, they have 
been attributed to an altered condition of the 
blood, and have been called Anaemic, Hsemic, 
or Blood Murmurs. As the condition of the blood 
is only one of the factors in their causation, and 
inasmuch as there is also in most of these cases 
dilatation of the heart, it seems probable, that 
many of these murmurs are due to this cause, 
and they are now often called Dilatation Murmurs. 

Such murmurs have for a long time been 
referred by many writers to regurgitation through 
the auriculo-ventricular orifices. Although it is 
difficult to understand, if this be the true explana- 
tion, why aneemic murmurs on the left side of the 



148 HOW TO EXAMINE THE CHEST. 

heart are not, like the ordinary regurgitant 
mitral murmurs, audible behind. 

When dilatation is extreme, the auriculo- 
ventrieular orifices certainly become permanently 
stretched, and too wide for the valves to close 
them completely. In this way regurgitation of 
the blood will occur, and a loud murmur be pro- 
duced, which may be extremely difficult to 
diagnose from the murmur due to regurgitation 
from organic disease of the valves. Such regur- 
gitation from stretching may occur on both sides 
of the heart, but it is commoner on the right 
side, and is the ordinary cause of systolic tricuspid 
murmurs. 



THE HEART. AUSCULTATION. 149 



EXOCAEDIAL MURMURS. 

Of the exocardial murmurs the most important 
is that, which is due to the rubbing together of 
the two layers of an inflamed pericardium. 

The healthy pericardium is smooth, and the 
movements of the heart within produce no 
sound. So soon, however, as the pericardium 
becomes roughened, as it does in pericarditis, a 
sound is produced. 

This has received the name of Pericardial 
Friction, 

It is rough, rubbing, grating in character, 
nearly always double (to and fro) . It appears 
superficial, i.e. close beneath the ear. It is 
usually not audible over a wide area, i.e. it is 
localised or limited in extent. It does not bear 
the same strict relation to the heart sounds, and 
is not propagated in the way that endocardial 
murmurs are. It frequently alters with the posi- 
tion of the patient, a phenomenon so unusual 
with other murmurs that it has been spoken of 
as pathognomonic of pericarditis. 

In most cases pericardial friction is easy to 
diagnose from the character of the sound alone, 
but in doubtful cases the correct diagnosis will 
be made by observing the relation of the mur- 



150 HOW TO EXAMINE THE CHEST. 

mur to the intervals of the heart, the effects of 
position, and the direction of propagation . 

The chief difficulty will arise, when the pleura 
is inflamed over the pericardium, from the fact 
that the movements of the heart may then cause 
a friction sound by rubbing the two layers of 
the roughened pleura together. Such friction is 
called Pleuropericardial, its seat being not in the 
pericardium, but in the pleura over the peri- 
cardium. 

Pleuropericardial friction is often altered by 
respiration, for a deep inspiration forces the 
lung between the two layers of roughened 
pleura and separates them, so that the friction 
will disappear for the time, to return again on 
expiration. This does not always happen, and 
in some cases respiration has no effect upon the 
sound. The difficulties of diagnosis will then be 
very great. 

Murmurs are occasionally heard over the prse- 
cordium, which have their seat not in the heart, 
but in the lung. They are produced probably 
by air being suddenly forced out by the move- 
ments of the heart from a portion of the lung 
in immediate relation with it, with force sufficient 
to produce a distinct blowing sound. 

Such murmurs are extremely rare. 



THE HEART. AUSCULTATION. 151 



MURMURS AUDIBLE IN OTHER PARTS OF THE 
THORAX. 

Aneurysms or dilatations of the aorta, or occa- 
sicmally the pressure of a mediastinal tumour 
upon the large vessels, may give rise to mur- 
murs, audible under the first piece of the sternum, 
or to one side of it. 

They are generally systolic, though some- 
times double, and are not easy to diagnose from 
murmurs due to disease of the aortic valves. 

In children a continuous murmur is sometimes 
heard in this place, when the head is thrown 
back, produced, it is stated, in the veins, by the 
pressure of large lymphatic glands in the medias- 
tinum. This explanation is, however, doubtful. 

Beneath the clavicle, a systolic murmur is 
frequently heard, the Subclavian Murmur. 

Its seat is in the subclavian artery, though its 
causes vary in different cases. 

It is sometimes due to compression of the 
artery by the muscles or by the stethoscope, 
and is then altered, or made to disappear, by 
changing the position of the arms or the 
pressure of the stethoscope. In other cases it 
occurs in connection with phthisis, and has been 
then referred to pinching of the arteries by 



152 HOW TO EXAMINE THE CHEST. 

adhesions at the apex of the lung, and, lastly, it 
may be due to aneurismal dilatation of the 
artery. 

A similar murmur, associated with vascular 
dilatation, is common in cases of exophthalmic 
goitre over the thyroid gland. 

Murmurs are frequently heard, also, in the 
Vessels of the Neck, both arteries and veins. 
Their commonest seat is in the root of the neck, 
just above the clavicles. 

In the Arteries, the murmur is systolic, and 
occurs in cases of anaemia. Such anaemic 
arterial murmurs are often difficult to diagnose 
from the murmurs propagated upwards along 
the vessels in cases of disease of the aortic 
valves. 

Venous Murmurs are sometimes heard in healthy 
people but are commonest in that form of extreme 
angemia, which is called chlorosis. 

"When in such a patient the stethoscope is 
placed above the clavicle over the origin of the 
sterno-mastoid muscle, a continuous blowing or 
rushing sound is heard, often mingled with hum- 
ming, or buzzing, semi-musical sounds, which 
have been compared with the buzzing of a fly. 

This is the Bruit du Diable or Nonnen-G-erausch. 
It is loudest usually on the right side. It is in- 
creased by pressure, although pressure alone is 
not sufficient to produce it, and may destroy it. It 



THE HEAET. AUSCULTATION. 153 

increases in intensity with whatever increases the 
rapidity of circulation through the veins. Hence 
it is loudest in the erect position, during the dias- 
tole of the heart, and during inspiration. 

The seat of the murmur is in the veins, for 
compression of the vessel with the finger above 
stops the murmur, with a pressure too small to 
have any effect upon the artery. 

Various explanations have been given of the 
murmur. It has been attributed to the peculiar 
condition of the blood (spanaemia), but as it is not 
heard in all cases of anaemia, it is more satis- 
factory to refer it, as also those similar murmurs 
in the heart, to a condition of dilatation. 

The anaemia produces from malnutrition a 
relaxed condition of the muscular tissue, the 
relaxed vessel dilates, wherever it can. Where, 
however, it passes through dense fascia, as at the 
root of the neck, this dilatation is prevented, and 
we have in this way produced a dilatation above 
and below, with an apparent constriction in the 
middle, the exact physical conditions for a mur- 
mur. 



154 HOW TO EXAMINE THE CHEST. 



SYNOPSIS. 

On Auscultation then we have to investigate, 

1. The Sounds of the heart : 

2. The Intervals between them : 

3. If Murmurs be present in the Cardiac Region ; 

1. Whether they are systolic, or diastolic, 

and if diastolic, to which part of the 
diastole they belong ; 

2. Their place of maximum intensity ; 

3. The direction in which they are propa- 

gated ; 

4. Any special peculiarities they may 

present : 

4. Murmurs elsewhere ; 

1 . Under the Manubrium Sterni ; 

2. In the vessels of the neck, 

1. Arteries ; 

2. Veins ; 

3. Beneath the clavicle. 



THE HEART, AUSCULTATION. 155 



SYNOPSIS OF THE EXAMINATION OF THE HEART. 

Inspection. 

1. The Shape of the precordial region. 

2. The Movements, the apex beat. 

impulse elsewhere. 

Palpation, 

1. The position of The Apex. 

2. Impulse elsewhere. 

3. Thrills, Valve-shock, Friction. 

Percussion. 

The Cardiac Dulness, its size, shape, and 
position. 

Auscultation. 

1. The Sounds of the heart. 

2. Murmurs. 

3. Friction. 

4. Murmurs elsewhere in thorax or neck. 



SECTION III. 



THE PULSE. 



THE EXAMINATION OF THE 
PULSE. 



When the left ventricle contracts, the blood, 
which is driven into the aorta, travels through 
the arteries in the form of a wave, and distends 
them, as it passes along. 

It is this wave of distension, which is felt, when 
the finger is placed upon the artery, and which is 
spoken of as the pulse. 

The Pulse might be examined in any superficial 
artery, but the Radial at the wrist is usually 
selected, because it is easily accessible, lying, as 
it does, close under the skin, and upon a solid 
backing of bone. 

In health, every contraction of the heart 
- produces a beat at the wrist, and we therefore 
commence the examination of the pulse by count- 
ing the Number of Beats in the minute. This is 
called the Pulse Rate. 

The Pulse Rate varies much in different individ- 
uals according to age, sex, temperament, &c, 
and also in the same, individual under. different 



160 



HOW TO EXAMINE THE CHEST. 



conditions, e.g. rest, exercise, emotion, &c, but 
the average in a healthy young man at rest is 
about 70, and in a woman about 80. In young 
children it is more rapid, and reaches 90 or 
100, while in infants it is about 120 (cf. Table). 

PULSE RATE AT DIFFERENT AGES. 

(From Carpenter's ' Physiology.') 

Beats per minute. 



In the foetus in utero . 


140—150 


Newly-born infant 


. 


. 130—140 


During 1st year 


. 


. 115—130 


„ 2nd year 


• 


100—115 


„ 3rd year 


. 


90—100 


From 7 th to 14th year 


80—90 


„ 14th to 21st 


year 


75—80 


„ 21st to 60th 


year 


70—75 


Old age 


. 


75—80 



In disease the number may rise to 140 or 150, 
and in children even up to 200. 

The beats then become often so rapid, that 
they appear to run into one another, and cannot 
be counted. The pulse is then called Running. 
The number rarely falls below 50, although cases 
are recorded, in which it did not exceed 40 or 
occasionally 30, or even less. 

The character of the wave will of course be 
much affected, not only by the force with which 
the heart contracts, and the amount of blood 
driven into the vessels, but also by the condition 
of the vessels themselves. 



THE PULSE. 161 

These different conditions must be clearly 
distinguished in making an examination of the 
pulse, and, before considering the characters of 
the pulse wave, we require to know all that we 
can ascertain about the condition of the artery 
itself, and the amount of blood which it contains. 

The Course of the Artery. 

A healthy radial artery runs a straight course 
down the forearm, but in disease and old age it 
is often much twisted, or, as it is called, Tortuous. 

The only superficial artery which is normally 
tortuous is the temporal. 

The Goats of the Artery. 

To estimate the thickness of the walls of an 
artery the tip of one finger, usually the index, is 
placed upon it, and pressed down so as to flatten 
it against the bone, and then moved slowly over 
it from side to side. 

In a healthy young person, the coats are thin 
and smooth, and flatten out under pressure, so as 
to lie like a piece of folded tape, and to be hardly 
detected under the finger. 

With increasing age, they normally become 
somewhat thicker, and are, therefore, more easily 
felt in the middle aged than in young persons. 

In disease and old age, the Thickening is often 

11 



1G2 HOW TO EXAMINE THE CHEST. 

so considerable, that the artery seems like a piece 
of thick straw, or even in extreme cases like a 
small pipe stem, and may be made to roll from 
side to side distinctly under the finger. 

This thickening is usually due to a disease of 
the inner coats called atheroma, which sometimes 
affects the whole vessel "Uniformly, at other times 
only parts of it, occurring then in Patches, which 
can often be easily felt. 

In other cases, as in granular kidney, the 
thickening is due to a Hypertrophy of the mus- 
cular or fibrous part of the artery, and is there- 
fore uniform aud general. 

Calibre of the Artery. 

But, apart from pathological change, the coats 
will appear to be thicker or thinner, according as 
the vessel is contracted or dilated. This of 
course stands in direct relation with what we 
have to consider next, viz. the Calibre of the 
Vessel, or the size of the column of blood which it 
contains. 

The blood in an artery is under pressure and 
tends therefore to dilate the vessel. This is re- 
sisted by the muscular and elastic tissue in its 
coats. As long as these opposing forces are 
normally related to one another, so long the calibre 
of the vessel will remain normal. 



THE PULSE. 163 

Dilatation may therefore occur in two ways, 
either in consequence of a deficiency of tone, as 
in fevers, or in consequence of an increase of in- 
ternal pressure or tension. 

Similarly contraction may occur, either in con- 
sequence of an excess of tone, as in granular 
kidney, or in consequence of a decrease of internal 
pressure, as in haemorrhage. 

In dilatation, the coats will feel thinner, and the 
artery softer and more easily compressible. 

In contraction, the coats will feel thicker, and 
the artery harder and less easily compressible. 

What the normal relation is between the thick- 
ness of the coats of a healthy artery and its 
calibre, can only be learnt by experience, but in 
all cases, as long as the vessel can be flattened 
out by pressure, so as to be not more distinctly 
felt than a piece of folded tape would be, so long 
the thickness, whatever this may seem to be, is 
only apparent and not real. 

Hard, soft, easily compressible &c, are terms 
often used in descriptions of the pulse, but they 
are confusing, for they may apply to very dif- 
ferent conditions. Thus, for instance, a cannon 
ball and a football are both hard, and not easily 
compressible, but for different reasons. In the 
one case the walls are rigid, and in the other the 
walls are tense. In describing the pulse it is 



164 



HOW TO EXAMINE THE CHEST. 



Fig. 35. 




The white line indicates the true curve of the pulse, the 
dotted line the sphygmographic tracing. 

I and II show the times at which the 1st and 2nd sounds of 
the heart occur. The systole lasts therefore from I to II, and 
the diastole from II to I. 

The wave, which is felt distinctly by the finger, corresponds 
in length with the line p, q. 

The single wave m is split up by the sphygmograph into the 
two waves a and e, and the second single wave ge into the two 
waves o and e. 

The diagram is taken, with modifications, from Dr. Galabin's 
Thesis for M.D. Cantab., 1873. 



THE PULSE. 165 

most important to distiuguish between these 
different conditions. 



The Pulse Wave. 

To examine the pulse wave, one finger say the 
index, is placed upon the artery with just suffi- 
cient pressure to feel the vessel when no wave is 
passing. When it passes, the finger will be jerked 
up, kept up for a short time, and then allowed 
gradually to fall, and we shall be able to form an 
estimate of the force, size, speed, and form of the 
wave. 

By means of the Sphygmograph all these various 
facts maybe recorded in a graphic form, the 
pulse or sphygmographic tracing {jig. 35). 

In the diagram a white line indicates what is 
probably the real curve, aud it differs in many 
respects from the sphygmographic tracing, which 
is represented by a dotted line. 

These differences are due chiefly to defects in 
the instrument, the lever being jerked up too 
high and then falling too low, and in this way 
giving a double wave where there ought only to 
be one. 

The sensation conveyed to the fingers repre- 
sents more nearly the real curve. This, we see 
rises sharply, then subsides slowly for some 
distance, until it is interrupted by another slight 



166 HOW TO EXAMINE THE CHEST. 

Fig. 36. 




Normal pulse tracing. 
Fig. 37. 




Tracing of a pulse of increased tension from a case of gran- 
ular kidney (square top). 

Fig. 38. 




Tracing of a dicrotic pulse. 
Fig. 39. 




Pulse tracing from a case of Aortic Incompetence. Water- 
hammer pulse. 

(Sudden rise and sudden fall.) 



THE PULSE. 167 

rise, after which it finally falls more rapidly down 
to the level from which it started. 

The only part which we feel distinctly is the 
top of the wave between m and ce in the diagram, 
and it is in this part that the most characteristic 
changes occur. 

The whole pulse wave extends of course from 
I to I, that is, from one beat to the next. A 
long wave would then be the same thing as a slow 
pulse. 

When we speak of a long wave in this sense, it 
will be better to call it a rapid or slow pulse, 
because we really refer to its frequency, and this 
will be discussed later, and because long and 
short are more commonly used in reference to 
the top or head of the wave (corresponding 
with the line p q) than to its total length. 

The parts of the wave to examine most 
attentively are the upstroke or rise, and the top 
or head. 

The Upstroke may be abrupt (fig. 39) or gradual 
(fig. 40), high (fig. 39) or low (fig. 37). 

The Top of the Wave (p to q) represents the 
maximum tension in the vessel. If it be well 
sustained (fig. 36 and 37), the subsidence will 
be gradual, if ill sustained, it will be abrupt 
{fig. 39.) 

Where it is gradual, the wave will appear long, 
and seem to pass slowly under the finger, and 



168 HOW TO EXAMINE THE CHEST.. 

where it is abrupt, it will appear short, and seem 
to pass rapidly under the finger. 

This is what is meant generally by a Long and 
Short Wave. 

When the tension is very low, the second wave 
(ce) is often well marked, and is sometimes as large 
and as distinct as the primary wave. The pulse 
is then felt as a double beat, and is called Dicrotic 
(twice beating) (fig, 38). 

In some other rarer cases, instead of two dis- 
tinct waves, several smaller ones are felt, and the 
pulse is called Thrilling, 

These thrills may in some conditions of the 
artery be produced by pressure, and on this 
account it is important to feel the pulse only with 
one finger, lest by a little unequal pressure vibra- 
tions may be set up, and the pulse made artificially 
thrilling. 

One of the most peculiar forms, and at the 
same time one of the most important clinically, 
is known as the Waterhammer Pulse (fig. 39). 
This is pathognomonic of incompetence of the 
aortic valves. It is characterised by a very high 
upstroke and by very short duration. 

It is a short sudden wave, and conveys to the 
finger the sensation of a sharp forcible jerk, the 
artery seeming to empty itself and collapse 
completely, almost immediately after the beat has 
been felt. 



THE PULSE. 169 

The high, upstroke is caused by the great force 
with which the blood is driven into the arteries, 
for the left ventricle is hypertrophied. 

The short duration or sudden collapse is due 
to the fact that the aortic valves do not close, so 
that the blood flows back from the aorta into the 
ventricles, and the tension in the arteries is not 
sustained. 

The position of the arm makes a great differ- 
ence in the distinctness with which the characters 
of this pulse are felt at the wrist. If the arm 
hang down, the force of gravity tends to keep the 
artery fairly full, but, if the hand be raised above 
the head, it helps to empty it, and the peculiarity 
becomes more marked. 

This pulse is also known by other names ; 

1. Corrigan's Pulse, from Dr. Corrigan who 
described it; 

2. The Locomotor Pulse, from the peculiar way, 
in which the impulse seems to travel down the 
arm, when it is so exposed that the whole length 
of the artery is visible ; 

And 3. The Pulse of Unfilled Arteries, because 
they so quickly empty themselves. If the stetho- 
scope be placed over a large artery, like the 
brachial or femoral, in such a case, a heavy thud 
is often heard, synchronous with the pulse. 
Possibly this may have given origin to the name 
waterhammer. 



170 HOW TO EXAMINE THE CHEST. 



Rhythm of the Pulse. 

In a healthy pulse the waves are equal in size, 
and follow each other at equal intervals of time. 
Where this is not so, the pulse is called Irregular, 
and it may be irregular (1) in Force, i.e. in the 
size of its waves, (2) in Frequency, i.e. in time, or 
(3) as is most common both in force and frequency 
(A/- 40). 

Fig. 40. 




Pulse tracing from a case of Mitral Incompetence. Pulse 
irregular in force and frequency. 



Irregularity of the pulse is usually due to 
irregular contraction of the heart, as the result 
either of muscular weakness or of impaired nerve 
control. 

Any nervous excitement may make both heart 
and pulse irregular for the time. And in some 
acute diseases of the brain and upper part of the 
spinal cord the rhythm of the pulse is often of 
diagnostic importance. In these cases the beats 
both of heart and pulse follow one another appar- 



THE PULSE. 171 

ently with regularity, but the frequency varies 
much from time to time even to the extent of 10 
or 15 beats in consecutive minutes. 

As a matter of routine then the pulse should 
be counted two or three times at short intervals. 

Muscular weakness of the heart often shows 
itself in the pulse by irregularity of force, i.e. in 
the size of the waves ; but this is usually associ- 
ated also with irregularity in time. 

When this weakness is great, some of the 
beats may fail to reach the wrist and the pulse 
is then called " Intermittent." In extreme cases, 
the pulse may be entirely absent at the wrist, 
the heart not having power to drive a single wave 
so far. 

In these cases any slight extra work thrown 
upon the heart, even for example, the effort of 
standing up, may increase the difference between 
the number of beats at the heart and at the 

ist. 

Although in most cases irregularity of the 
pulse is due to irregularity of heart action, 
there are cases in which the pulse is markedly 
irregular, while the heart continues to beat regu- 
arly. 

This irregularity is generally synchronous with 
:he respiratory movements, and in this way 
regular oscillations in the pulse tracings are pro- 
luced. 



172 HOW TO EXAMINE THE CHEST. 

In health, this is not detected except by deli- 
cate apparatus in the large vessels near the 
heart, but, where the circulation is feeble, it may- 
be observed at the wrist in an irregularity, not 
only of force but also of time, synchronous with 
the inspiratory movements of the chest. 

In the most extreme form, this gives rise 
to the Pulsus Paradoxus, {fig. 41), or Pulsus cum 

Fig. 41. 




Pulsus Paradoxus. Pulsus cum luspiratione intermittens. 
Taken from a case of Purulent Pericarditis. 

The pulse is very dicrotic, the second wave being almost as 
large as the first. The horizontal line indicates the remissions 
due to inspiration, and lasting for two or three heart beats. 

luspiratione intermittens. The pulse beat then 
disappears entirely during inspiration, and often 
hardly a trace of vibration can be detected even 
upon an enlarged sphygmographic tracing. In 
the most typical form the heart remains perfectly 
regular, both in force, as judged by the loud- 
ness of the heart sounds, and in time. 

The typical pulsus paradoxus is very rare. Its 
causes vary. In some few cases, the heart seems 
to be in such an extreme condition of muscular 



THE PULSE. 173 

feebleness, that it is unable to overcome even 
the very slight increase of work, which inspira- 
tion throws upon it. 

In most cases, however, the pulsus paradoxus is 
found to be caused by adhesions or bands, which 
surround the large vessels either in the medias- 
tinum or within the pericardium, in such a way 
that, when the chest expands on inspiration, they 
are tightened, the vessels compressed or pinched, 
and the pulse wave stopped. 



Want of Symmetry. 

The pulses in the two wrists in health are 
exactly symmetrical, both in time and force, the 
only allowance, that may have possibly to be 
made, is for an anatomical difference in the size 
of the vessel, but this does not often prove to be a 
practical difficulty. 

In disease of various kinds, the artery of one 
side may be twisted, pressed upon, stretched, or 
displaced in such a way as to obstruct the circu- 
lation through it, and thus a Want of Symmetry 
will be produced. 

Usually this shows itself in an alteration in 
the Character of the Wave on the affected side, 
which may be recognised by the finger and des- 
cribed upon a sphygmographic tracing, but 



174 



HOW TO EXAMINE THE CHEST. 



besides this the wave is often Retarded, so that it 
reaches the wrist on the affected side at a per- 
ceptibly later time. 

These, like all other defects of symmetry, are 
of very great practical importance in the diag- 
nosis of disease. 



THE PULSE. 175 



SYNOPSIS OF THE EXAMINATION OF THE PULSE. 

I. The Artery. 

1. Its course, straight, tortuous. 

2. Its coats /"thinned. 

\ thickened Ca. Uniformly. 
\b. In patches. 

II. The Calibre of the Vessel, i e. 9 the size of the 
column of blood it contains, and the relation 
between it and the thickness of its coats. 

III. The Pulse wave. 

1. Its frequency, i.e. the number of beats in 

the minute. 

„ T ^ ( Irregular j' infor f' 

2. Its rhythm < t or m frequency. 

C Intermittent. 

3. The wave. 1. Its rise, high or low. 

2. Its head j l°ng and short. 

C rapid or slow. 

3. Its character (dicrotic, 

thrilling, waterhammer, 
&a). 

4. Its symmetry, in time and 

force. 



SECTION IV. 



THE MEDIASTINUM. 



12 



THE EXAMINATION OF THE 
MEDIASTINUM. 



The Mediastinum is the irregular space, extend- 
ing from the first rib to the diaphragm, and 
lying between the sternum in front, the spine 
behind, and the lungs on either side. 

Part of this space is occupied by the heart, the 
rest contains the large arteries and veins con- 
nected with the heart, the trachea and the roots 
of the lungs, the oesophagus, and thoracic duct, 
with numerous nerves, small vessels, and glands. 

Dislocation of the Mediastinum. 

All these structures are intimately connected 
together, and form a mass which is firmly fixed 
below by its attachment to the diaphragm, and 
posteriorly and above by its attachment to the 
spinal column, so that vertical displacement 
is hardly possible. With the sternum, however, 
the connections are loose, so that Lateral Displace- 



180 HOW TO EXAMINE THE CHEST. 

ment may occur by a kind of rotation, as a door 
swings upon its hinge, the hinge in this case 
being the aorta, where it is fixed to the spine. 

The mediastinum remains in the middle line in 
health. Not because it is " fixed " there, but 
because of the equal balancing of the forces, 
which tend to displace it on either side. The 
chief of these is the elasticity of the lungs. 

If air be admitted freely into one pleural cavity, 
the lung on that side collapses, and the elasticity 
of the other lung, being unopposed, comes also 
into play. This lung, then, also contracts, and in 
doing so pulls over the mediastinum. 

If one pleural cavity be greatly distended by 
air or fluid, the mediastinum will be pushed over 
by the pressure and will be still further displaced 
(figs. 15 and 16). 

On the other hand, if one pleural cavity be 
contracted, as with the fibroid thickening, which 
often occurs after chronic pleurisy, the medias- 
tinum will be pulled over, just as the ribs on that 
side are pulled in (fig. 14). 

The Physical Signs of Displacement of the Medi- 
astinum en masse are 

1. Those of displacement of the heart (g. v.) ; 

2. Those of displacement of the anterior boun- 
daries of the lungs (g. v.). 

These have been already discussed, and need 
not be further referred to here. 



THE MEDIASTINUM. 181 

The parts of the Mediastinum. 

The Heart, although strictly included in the 
mediastinum, has been already described in a 
separate chapter. 

The Rest of the Mediastinum is not so easily 
accessible. 

The places where it is examined are 

1. In front, beneath the upper part of the 
sternum; 

2. Behind, on either side of the dorsal vertebras 
in the interscapular spaces. 

Diseases of the Mediastinum. 

In front, the mediastinal region extends from 
the episternal notch down the sternum to the 
level of the fourth costal cartilage. 

This part in health is slightly prominent, moves 
slightly with respiration, and is resonant to per- 
cussion. Beneath it, distinct tracheal or bron- 
chial breathing and resonance, are usually 
audible. 

Apart from affections of the lungs and pleura, 
which may modify the physical signs here (p. 
54, &c.) the diseases of this part are chiefly two, 
each attended by the formation of a Tumour, viz. 
Aneurysm or New Growth. 

In either case the lungs are pushed aside by a 



182 



HOW TO EXAMINE THE CHEST. 



Fig. 42. 




Diagram of a Mediastinal Tumour. The shaded area beneath 
the manubrium and upper ribs indicates the area of impaired 
percussion resonance. 

The edges of the lungs are retracted, or pushed aside by the 
mass beneath. 



THE MEDIASTINUM. 183 

mass, and their place beneath the sternum is 
taken by the non-resonant tumour (Jig. 42). 

The percussion will be, therefore, impaired or 
dull, and, as in the lungs, we shall obtain usually 
the physical signs of consolidation, viz. increased 
vocal vibration, increased vocal resonance, and 
increased breathing sounds. In addition there 
may be present in some cases Bulging, Pulsation, 
Thrills, or Rubbing, and occasionally also Vascular 
Murmurs. 

Posteriorly, in the interscapular spaces, the 
same two diseases are met with, and may give 
rise to the same physical signs. 

Impairment of percussion is, however, much 
more difficult to make out, because of the thick 
muscular covering to the ribs, the percussion 
note here being normally deficient in tone, but 
of course symmetrical. Want of symmetry is 
what we look for, and this is often very distinct, 
so far as vocal vibrations, vocal resonance, and 
breathing sounds are concerned, although the 
other physical signs which are occasionally present 
in front, viz. bulging, pulsation, thrills, friction 
and murmurs, are very rarely obtained behind. 

Where the tumour is large, not only the lungs 
but also the heart and diaphragm may be pushed 
out of place, and we shall then have, in addition, 
the ordinary physical signs of displacement of 
these organs. 



184 HOW TO EXAMINE THE CHEST. 



The Diagnosis of Diseases of tJie Mediastinum. 

The diagnosis of mediastinal affections, by- 
means of the physical signs alone, is often very 
difficult, especially when the disease is not exten- 
sive, and is deeply seated, and it is then rather 
upon the secondary symptoms, to which the 
disease gives rise, than upon the physical signs, 
that the diagnosis depends. 

These Secondary Symptoms are for the most 
part due to mechanical interference, by pressure, 
with the function of the various organs in the 
thorax. 

What these symptoms may be, depends upon 
the part pressed upon, and varies according to 
the seat of the disease, and, to determine this, a 
very intimate knowledge of the relationship of 
the different parts in the mediastinum is essential. 
These are given in detail in any good work on 
anatomy. It will be sufficient for our present 
purpose to group the various symptoms together 
with reference to their cause, and to indicate 
in this way the use, which may be made of them 
for diagnosis. 

I. Pressure upon the Vessels will lead to inter- 
ference with the circulation through them. 

When the Veins are compressed, the part of 



THE MEDIASTINUM. 185 

the vessel on the side away from the heart will be 
distended, and an attempt will be made to estab- 
lish the circulation through collateral channels. 
This will give rise then, first, to Distension of 
the Large Veins above the seat of pressure, as is 
especially common in the lower part of the neck, 
or on the shoulders, and, secondly, to abnormal 
Dilatation of the Subcutaneous Veins usually over 
the front of the chest.* 

In both cases the distension is usually unsym- 
metrical. 

It is important to determine in all these cases 
the direction in which the blood is travelling 
in the dilated vessels, in the way described at 
p. 20. 

The circulation through the Arteries may be 
interfered with, either as the result of direct 
pressure upon them, or in consequence of the 
vessels being so twisted or stretched at their 
origin, that their mouths are obstructed. 

In either case the Pulse, cardiac or radial, will 
become unsymmetrical. There will be a differ- 
ence either in force or in time, that is to say, one 
pulse will be either Smaller than the other, or 
will reach the wrist later than the other, i.e. be 
Retarded. 

* The physiological dilatation of the mammary veins re- 
ferred to at p. 20 must not be confounded with this patho- 
logical dilatation. 



186 HOW TO EXAMINE THE CHEST. 

Pressure upon either arteries or veins may pro- 
duce a Murmur, audible of course near the seat of 
pressure. In the arteries it is usually Systolic, 
and in the veins often Continuous. 

II. Pressure upon the Respiratory Tract will 
lead to interference with respiration, and give rise 
to Dyspnoea, Stridor, or Cough, all of which are 
frequently Paroxysmal. 

Dyspnoea may be due to pressure upon the 
trachea or bronchus, or directly upon the lung 
itself, and similarly cough may be the result of 
irritation of any of these parts. 

Stridor, whether in breathing, speaking, or 
coughing, on the other hand, is always evidence 
of pressure upon the trachea or bronchi, if there 
be not a local affection of the larynx to account 
for it, as can easily be determined by laryngo- 
scopy examination. 

Where the pressure is upon the trachea, the air 
will have difficulty in entering both lungs equally, 
but where it is upon the bronchus or lung of one 
side, the obstruction is unilateral, and, therefore, 
we shall find a want of symmetry in the physical 
signs ; the vocal vibrations and the vocal resonance 
may be weaker than on the unaffected side, and 
the respiratory murmur may be feebler or often 
altered in character, expiration especially becom- 
ing prolonged and occasionally wheezing. 

The place to examine for these altered physical 



THE MEDIASTINUM. 187 

signs is as far away as possible from the root of 
the lungs, where, as a rule, the obstruction exists ; 
and the most convenient part to select is low 
down at the base of the lungs posteriorly, i.e. in 
the infra-scapular region. 

In such cases as these a slight want of sym- 
metry may be of great importance. 

III. The symptoms of Pressure upon the Nerves 
vary with the nerve affected, and with the 
amount of pressure, slight pressure producing 
the results of irritation, and considerable pres- 
sure those of paralysis. 

The nerves are the Pneumogastric, the Phrenic, 
the Sympathetic, and the Intercostal. 

1. Of these, the most important is the Pneumo- 
gastric, distributed, as it is to the larynx, lungs, 
and heart. 

The Recurrent Laryngeal Branch on the left 
side, where it winds round the arch of the aorta, 
is especially exposed, and is therefore often 
affected. 

Irritation of this branch, as also of the pulmo- 
nary branches of the pneumogastric, commonly 
produces attacks of Spasmodic Dyspnoea, which 
are sometimes fatal. 

Paralysis, on the other hand, expresses itself in 
loss of voice, Aphonia, in consequence of paralysis 
of the vocal cord upon the side affected. 

The effect upon the heart is usually to produce 



188 HOW TO EXAMINE THE CHEST. 

Irregularity, Palpitation, and Paroxysmal Pain, 
and occasionally sudden death from Syncope. 

2. Pressure upon the Intercostal Nerves gives 
rise to Pains, referred usually to their peripheral 
distribution on the side or front of the thorax, or 
occasionally following the course of the intercosto- 
humeral nerve, down the inner side of the arm as 
far as the elbow. 

Paralysis of the intercostal nerves is not 
common. 

3. The Phrenic Nerves usually escape or at all 
events the diaphragm rarely gives evidence of 
any affection, when only one phrenic is in- 
volved. 

4. The Sympathetic Nerves enter largely with 
the spinal nerves into the various plexuses in the 
thorax, and cannot be separated in their action 
from the spinal nerves already referred to, unless 
certain alterations in the rate of beating of the 
heart be attributed to their influence. 

IV. Pressure upon the Thoracic Duct produces 
no symptoms, by which it can be diagnosed, 
although theoretically it might be the cause of 
ansemia and malnutrition. 

V. Lastly, Pressure upon the (Esophagus causes 
Dysphagia, i.e. difficulty in swallowing either 
solids or liquids, and occasionally, where the 
obstruction is considerable, it may lead to Regur- 
gitant Vomiting. 



THE MEDIASTINUM. 189 

It is the combination and association of these 
various symptoms, which make it possible to 
determine in a given case the locality of a tumour 
in the thorax. 

All that the physical signs enable us to estab- 
lish in many cases is the presence of a tumour 
in some part of the mediastinum. Its nature, 
whether aneurysm or new growth, has often to 
be decided rather by the general or constitutional, 
than by the physical signs. 

In young or old people, the probabilities are in 
favour of new growth ; especially if the cachexia, 
usual with malignant disease, be present. 

On the other hand, in middle aged persons 
especially in men, the probabilities are in favour 
of aneurysm. This diagnosis would be confirmed 
by evidence of vascular change in other parts, as 
for example by thickened arteries, or by the his- 
tory of causes likely to produce vascular degene- 
ration, such as laborious work, drink, and 
syphilis. 

In the majority of cases, however, the diagno- 
sis does not present any great difficulties. 



190 HOW TO EXAMINE THE CHEST. 



SYNOPSIS. 

In making the diagnosis of a mediastinal 
tumour, we have to consider 

1. The evidence of a solid mass in the medias- 
tinum, as given 

(a) By the physical signs, 

(b) By the pressure symptoms ; 

2. The facts pointing to the nature of the 
mass; 

(a) Special physical signs; 

(b) The age, history, and constitutional 
condition of the patient. 



INDEX. 



A. 

PAGE 
Abdominal respiration . 20 
Absolute cardiac dulness . Ill 
Accentuation of the heart 

sounds . . . 124 
^Egophony . . .69 

Air, amount of, on respira- 
tion . . . .21 
Alar chest, the . . .17 
Amount of air on respira- 
tion . . . .21 
Amphoric breathing . . 74 

— whisper . . .68 
Anaemic murmurs . . 147 
Aneurysm, thoracic . . 181 
Aortic disease, alteration 

of cardiac dulness in . 117 

— murmurs . . ,139 
Apex of the heart, the . 99 

— displacements of the . 100 
Arch, the costal . . 1 
Area, the cardiac . . 110 

— the splenic . . .43 

— of stomach resonance . 43 
Arterial murmurs in neck . 152 

— pulsation . . . 103 
Arteries, calibre of . . 162 



PAGE 

Arteries, changes in coats of 161 

— pulse of unfilled . . 169 

— tortuous . . . 161 
Asymmetry of thorax in 

disease of the lungs 18, 25 

Asystolism . . .123 
Auricular systolic murmurs 129 

Auscultation . . 5, 60 

— of the breathing sounds 64 

— of the heart . . . 118 

— of the voice . . .64 
Autophony . . .69 
Axes of heart . . . 137 
Axillary region, the . . 2 
Axes of aorta . . . 138 

— mitral orifice . . 139 

— pulmonary orifice . . 138 



B. 

Backward murmurs . . 133 
Bad breathing (dyspnoea) . 22 
Barrel-shaped chest, the . 13 
Bell sound, the . . .87 
Bladder, position of the 

gall . . ... 41 



192 



INDEX. 



Blood current, in dilated 




superficial veins, direc- 




tion of 


20 


Blood murmurs 


147 


Boundaries of the lungs . 


35 


— displacement and dislo- 




cation of . 


49 


Boundaries of the liver 


39 


Breathing, alteration of, in 




disease 


78 


— Cheyne-Stokes's 


. 


24 


— sounds 


. 


70 


— varieties of . 


, 


71 


Bronchial breathing 


. 


171 


— resonance 


. 


65 


— whisper 


. 


68 


Bronchophony . 


. 


65 


— whispering . 


. 


68 


Bruit d'airain . 


. 


87 


— du diable 


. 


152 


Bruit de pot fele 


. 


53 


Bulging, expiratory 


. 


23 


— of chest in disease of 




lungs .... 


18 


— of the praecordium 


. 


98 



Callipers . . . .11 

Cantering action of the 

heart . . . .123 

Capacity of the chest, the 

vital .... 21 

Cardiac dulness, the altera- 
tions in 113 



PAGE 

Cardiac dulness, the area 

of absolute . . Ill 

— the area of relative • 112 
Cardiac impulse . . 102 
Carinate chest . . .17 
Carpenter's chest . ■ 19 
Cataire, fremissement . 107 
Cavernous breathing . . 74 

— whisper . . .68 
Chest, the . . .1 
Chest, alar . . .17 

— barrel-shaped . . 13 

— change of shape of, in 

disease . . .18 

— measurements of . .10 

— paralytic . . .17 

— pigeon-breast . .15 

— position of patient on 

examining the . . 3 

— pterygoid . . ,17 

— rickety . . .14 

— varieties of . . .12 

— variations in shape of . 9 
Cheyne-Stokes's breathing 24 
Clavicular region, the . 2 
Compensatory hypertrophy, 

or emphysema . . 49 

Complemental space . . 39 

Consolidation of lung, the 

diagnosis of . .80 
Contents of the thorax, the 3 
Contraction of chest in dis- 
ease of the lungs . 18 

— of lungs . . .47 
Corrigan's pulse . . 169 



INDEX. 



193 





PAGE 


Costal arch, the 


. 1 


— respiration . 


. 26 


Count the ribs, how to 


: 27 


Cracked-pot sound . 


. 55 


Crepitation 


. 81 


— fine hair 


. 82 


— metallic 


. 86 


— redux . 


. 85 


— to be felt 


. 28 


Croup, chest in 


12,23 


Crying, resonance of 


. 68 


Cyrtometer 


. 11 



D. 



82 



Death rattle, the 

Deep cardiac dulness, the 

area of . . .111 
Defective inspiration. . 22 
Deficient expansion . . 22 

— expiration . . . 22 

— resonance on percussion 55 

— respiratory movement . 22 
Deformities of chest . . 19 
Diagram of heart sounds . 110 
Diaphragmatic respiration 20 
Diastole .... 126 
Diastolic impulse . . 103 

— murmurs . . . 126 
Dicrotic pulse . . . 168 
Difficulty in breathing . 22 
Diffused cardiac impulse . 102 
Dilatation murmurs . . -147 

— of superficial veins . 19 
Direct percussion . . 31 



PAGE 

Direct vocal resonance , 68 
Direction of blood- current 

in superficial veins . 20 
Displacement of boundaries 

— of the lungs . . 49 

— of the heart . . 98 

— of the mediastinum . 179 
Dry sounds . . .81 
Dulness, percussion . . 34 
Dyspnoea, expiratory . 22 

— inspiratory • . .22 



E, 



of 



Effusion, boundaries 

lungs in pleuritic . 57 
Emphysema, compensatory 49 

— expiratory bulging in . 23 

— physical signs of . .47 

— senile . . . .47 

— shape of chest in . .13 
Endocardial murmurs . 125 
Enlargement of the lungs . 47 
Epigastric pulsation . . 102 
Episternal region, the . 2 
Exaggerated resonance . 55 

— respiratory movements . 22 
Examination, methods of . 3 
Exocardial murmurs . 125, 149 
Expansion, deficient . . 22 
Expiration, deficient . . 22 
Expiratory bulging . . 23 

— dyspnoea . . .22 
Extended cardiac impulse . 102 

13 



194 



INDEX. 



PAGE 

Fine hair crepitation . . 81 
Fluctuation . . .20 
Fluid in pleura, diagnosis of 80 
Forms of chest ... 9 
Fremissenient cataire. . 107 
Friction felt on palpation . 28 

— pericardial . .107, 149 

— pleuritic . . .84 

— pleuro-pericardial . 85, 150 

— redux . . . .85 
Furrow, Harrison's . . 15 

G. 



Gall-bladder, position of . 


41 


General heaving of praecor- 




dium . 


104 


H. 




Hsemic murmurs 


147 


Hammers for percussion . 


31 


Harrison's furrow- 


15 


Heaving of prsecordium, 




general 


104 


Heart, the . 


97 


— apex of. 


99 


— auscultation of 


118 


— axes of . 


137 


— cantering action of 


123 


— diagnosis of valvular 




diseases of . 


141 


— displacement of . 


98 


— how to time 


122 


— impulse of . 


102 


— inspection of 


98 



PAGE 

Heart, palpation of the . 107 

— percussion of the . . 109 

— valves, position of . 135 
Heart sounds, the . .119 

— accentuation of the . 124 

— reduplication of the . 123 

— unduly audible in disease 

of lungs . . .68 
Hepatic pulsation . . 103 
Hydro-pneumothorax . 87 

Hyper-resonance . . 53 
Hypertrophy, compensatory 49 



I. 



31 



Immediate percussion 
Impaired resonance on per- 
cussion . . .55 



— niurnmrs {vide murmurs) 124 



— respiratory movements . 
Impulse, diastolic 

— of the heart . 
Increased resonance on per- 
cussion 

Indirect percussion . 
Infraclavicular region, the 
Inf ramammary region, the 
Inf rascapular region . 
Infraspinous region, the 
Inorganic murmurs . 
Inspection of the heart 
Inspiration, defective 
Inspiratory dyspnoea 

— recession 
Intercostal spaces, bulgin 

of . 



22 

103 
102 

55 

31 

2 

2 

2 

2 

146 

98 

22 

22 

23 

23 



INDEX. 



195 



PAGE 

Intercostal, contraction of 28 

— recession of . . .23 

— widening of . . .28 
Intermittent pulse . . 171 
Interrupted breathing . 75 
Interscapular region, the . 2 
Irregular pulse . . . 170 

— respiration . . .24 



Jerky breathing 



75 



K. 



Klappenstosz (valve shock) 108 



Landmarks, medical (see 

Surface markings) . 35 
Laryngeal breathing . 71 

— resonance . . .65 
Line, the nipple . . 2 
Liver, surface markings of 30 
Locomotor pulse, the . 169 
Lungs, auscultation of the 60 

— boundaries of the . . 37 

— consolidation of the . 80 

— contraction of the . . 47 

— diagnosis between dis- 

ease of the pleura and 

of the ... 80 

— enlargement of the . 47 

— inspection of the . . 9 

— palpation of the . . 27 

— percussion of the . . 31 

— size of the . . .35 



M. 

PAGE 

Mammary region, the . 2 
Markings, surface . . 35 
Measurements of chests . 10 
— ■ varying with respiration 21 
Mediastinum . . . 179 

— boundaries of . .179 

— diagnosis of diseases of . 184 

— diseases of . . . 181 

— dislocation of . . 179 

— parts of 181 

— places to examine . . 181 

— synopsis of examination 

of .... 190 

Mediate percussion . . 31 

Medical landmarks . . 35 

Metallic ciepitation . . 86 

— tinkling ... 86 
Methods of examination . 3 
Mitral disease, alteration of 

cardiac dulness in . 117 

— murmurs . . . 139 

— stenosis, case of . . 143 
Moist sounds . . .81 
Movements of respiration, 

alterations in .22 

— how to examine, by 

palpation . . .27 

— of chest in respiration . 20 

— of the prsecordium . 98 
Murmurs, ansernic, haemic, 

blood . . .147 

— aortic .... 138 

— auricular systolic . . 128 

— backwards . . . 133 



196 



INDEX. 



PAGE 

Murmurs, cause of endo- 
cardial . . . 132 

— classification of . . 125 

— definition of . . . 124 

— diastolic . . .129 

— dilatation . . . 147 

— endocardial, not due to 

valvular disease . . 145 

— endocardial and exo- 

cardial . . . 125 

— exocardial . . . 149 

— heart . . . .124 

— how to time . . 126 

— inorganic, characters of 146 

— in vessels of neck . 152 

— mitral . . . .139 

— musical . . .125 

— onwards . . . 133 

— organic and inorganic . 126 

— place of . . .133 

— postsystolic . . . 131 

— presystolic . . . 128 

— pulmonary systolic . 146 

— subclavian . . . 151 

— systolic and diastolic . 126 

— table of 132 

— tricuspid . . 141, 147 

— venous . . .152 
Musical heart murmurs . 125 

N. 

Nipple line, the . . 2 

Nonnen-gerauseh . . 152 
Number of respirations . 23 



0. 

PAGE 

Onwards murmurs . . 133 
Orthopncea . . .22 



P. 

Palpatory percussion . 32 

Palpation .... 5 

— of heart . . .166 

— of lungs . . .27 
Pantograph . . .12 
Paradox pulse, the . . 172 
Paralytic chest, the . . 17 
Parasternal region, the . 2 
Pectoriloquy . . .68 

— whispering . . .68 
Percussion ... 5 

— apparatus for . . 91 

— boxy . . . .55 

— deficient . . .55 

— definition of . . .31 

— direct (immediate) . 31 

— dull .... 55 

— exaggerated . . .53 

— impaired . . .55 

— indirect (mediate) . . 31 

— method of . .32 

— normal . . . .55 

— of the heart . . .109 

— of lungs . . .31 

— palpatory . . .32 

— sounds, varieties of . 51 
Pericardial effusion, altera- 
tion of cardiac dulness 

in . . . .117 



INDEX. 



197 



PAGE 
. 167 
. 149 
. 15 
. 31 
. 31 



Pericardial friction 

characters of 

Pigeon breast, the 

Plessirneters 

Plessor 

Pleura, diagnosis between 
diseases of lung and 
of . . . .80 

Pleuritic effusion , . 51 

diagnosis of . .80 

— friction . . .84 

felt on palpation . 28 

Pleuro-pericardial friction 

65, 150 
Pneumothorax, ausculta- 
tion in . . .85 

— boundaries of lungs in . 49 
Position of patient for exa- 
mination of the chest . 3 

Postsystolic murmurs . 130 

Praecordium, the . . 98 

— bulging of . . .98 

— the movements of . .98 

— the shape of . . .98 
Presystolic murmurs . 128 
Pterygoid chest, the . . 17 
Puerile breathing . . 75 
Pulmonary systolic mur- 
murs .... 146 

Pulsation, arterial . . 103 

— epigastric . . . 103 
— • hepatic . . . 103 

— venous .... 104 
Pulse, the . . . . 159 

— Corrigan's . . . 169 



PAGE 

Pulse, cum inspiratione in- 
termittens . . . 172 

— dicrotic . . . 168 

— hard, soft, &c. . . 163 

— incompressible . . 163 

— intermittent . . . 171 

— irregular . . . 170 

— locomotor . . . 169 

— of unfilled arteries . 169 

— paradox . . . 172 

— relation to respiration . 23 

— retardation of . . 174 
— ■ rhythm of . 170 

— synopsis of the . . 175 

— thrilling . . . 168 

— want of symmetry . 173 

— waterhammer . . 168 
Pulse rate, the . . . 159 
conditions affecting 

the ... . 160 

Pulse wave, the . . . 165 

Purring tremor . . 107 

Pyo- pneumothorax . . 87 

R. 

Rales . . . .81 

Rate of respiration . . 23 

Rattle, the death . . 82 

Recession, inspiratory . 23 

— of apex beat systolic . 102 
Reduplication of the heart 

sounds . . . 123 

Redux crepitation . .85 

— friction . . .85 
Regions of chest . . 2 



198 



INDEX. 





PAGE 


Relative cardiac dulness . 


Ill 


Resistance, sense of . 


29 


Resonance, percussion 


34 


— area of stomach . 


43 


— deficient 




55 


— dull . 




55 


— impaired 




55 


— normal 




55 


— tympanitic . 




53 


— varieties of . 


. 


51 


— vocal, varieties of 


65 


Respiration 




— amount of air on . 


21 


— Cheyne-Stokes's . 


24 


— costal or thoracic . 


20 


— diaphragmatic or abdo- 




minal 


20 


— effect of emotion on 


24 


— interrupted . 


75 


— irregular 


24 


— jerking 


75 


— movements of 


20 


— Saccadee 


75 


— variations in move- 




ments of 


22 


— voluntary control over . 


24 


— wavy .... 


75 


Respirations, effect of ex- 




citement and disease 




upon number of . 


23 


— number of . 


23 


— relation to pulse . 


23 


Respiratory movements, 




how to examine (pal- 




pation) 


. 


27 



PAGE 

Respiratory movements in 
men, women, and chil- 
dren .... 20 

Rhonchus . . . .81 

— felt ... 28 
Ribs, how to count the . 27 
Rickety chest, the . . 14 

S. 
Senile emphysema . . 47 
Sense of resistance . . 29 
Shape of the healthy thorax 9 

— varieties of . . .12 
Shoemakers' chest . . 19 
Short breath (dyspnoea) . 22 
Sibilus .... 81 

— felt .... 28 
Solidification of lung, dia- 
gnosis of . . .80 

Sound, cracked-pot . . 55 

— the bell ... 87 

— the splashing . . 87 
Sounds, dry and moist . 82 
Sounds of breathing . . 70 

— of the heart, the (see 

Heart sounds) . . 119 

— whisper . . .68 

Space, complemental . . 39 
Spaces, bulging of inter- 
costal . . . .28 

— contraction of intercostal 28 

— widening of intercostal 28 
Sphygmograph, the . . 165 
Spirometer, the . . 21 
Splashing sound . . 87 



INDEX. 



199 



PAGE 




PAGE 


Splenic area 


43 


Synopsis of general exa 




Stethoscopes 


60 


ruination of the medi- 




— binaural 


63 


astinum 


190 


— single .... 


62 


of the pulse . 


175 


Sternal region, the . 


2 


— of inspection of heart 


105 


Stomach resonance, the area 




of lungs 


26 


of ... 


43 


— of palpation of heart . 


108 


Stomach, size of 


43 


— — of lungs . 


30 


Stokes's breathing, Cheyne- 


24 


— of percusssion of heart . 


117 


Stridor, stridorous breath- 




of lungs . 


50 


ing ... . 


171 


Systole . 


120 


Subclavian murmurs 


151 


Systolic murmurs 


126 


Succussion 


87 


— pulmonary . 


146 


Supraclavicular region, the 


2 


Systolic recession of apex 




Supraspinous region, the . 


2 


beat .... 


102 


Superficial cardiac dulness, 








the area of . 


110 


T. 




— veins, dilatation of 


19 


Thoracic aneurysm . 


181 


Surface markings 


35 


— respiration . 


20 


— liver . . 


39 


— tumour 


181 


— lungs .... 


44 


Thorax, the 


1 


— spleen . . . 


43 


— changes in shape of, in 




— stomach 


43 


disease 


18 


Symmetrical contraction of 




— measurements of . 


10 


lungs .... 


47 


— contents of the . 


3 


— enlargement of lungs . 


47 


— parts of the 


1 


Symmetry in shape of 




— varieties of . 


12 


thorax, want of, evi- 




Thrilling pulse . 


168 


dence of disease . 


18 


Thrills . 


107 


Synopsis of auscultation of 




Tinkling, metallic 


86 


heart .... 


154 


To time the heart 


127 


— auscultation of lungs . 


89 


Tracheal breathing . 


71 


Synopsis of general exami- 




— resonance 


65 


nation of heart . 


155 


Tracing, cyrtometer, of 




of lungs 


93 


chest . 


11 



200 



INDEX. 



PAGE 

Tracing, sphygmographic . 165 

Transposition of viscera . 101 

Traube's zone . . .43 

Tremor, purring . . 107 

Tricuspid murmurs . . 147 

Tubular breathing . . 71 

Tumour, mediastinal . . 181 

Tympanitic resonance, or 

percussion . . .53 

Types of respiration . . 26 

U. 

Undulatory cardiac impulse 102 
V. 

Valve shock . . . 107 
Valves of heart, position of 135 
Valvular disease, diagnosis 

of . . .141 

Varieties of chests . . 12 
Veins, dilatation of . .19 
Venous murmurs in neck . 152 
Venous pulsation . . 103 
Vesicular breathing . . 71 
— resonance . . .65 
Vibrations of voice in 

women and children . 29 



PAGE 
Vibrators, want of sym- 
metry in . . . 29 

— vocal .... 28 
Viscera, transposition of . 101 
Vital capacity of the chest 21 
Vocal resonance . 29, 64 

— varieties of . . .65 
Vocal vibrations . . 28 
Voice, auscultation of the . 64 

W. 



Want of symmetry in 


the 




lungs . 


. 


18 


On inspection . 




25 


— palpation . 




29 


— percussion . 




56 


— auscultation 




90 


Waterhammer pulse . 




16S 


Wavy breathing 




75 


Weaver's chest . 




19 


Whisper sounds . 




68 


Widening of intercostal 




spaces 




28 


Z. 






Zone, Traube's . 




43 



PRINTED BY J. E. ADLARD. BARTHOLOMEW CLOSE. 



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